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The Vagina Dialogues

By Erika Engelhaupt
The women's health questions you were afraid—or never knew—to ask.

“Vagina, vagina, vagina!”

You’ll hear that word often in the office of Hopkins gynecologist Wen Shen, and more. “We talk about everything. There’s no holding back,” Shen says.

Shen wants women to get comfortable talking about uncomfortable topics, and so do we. Women have gotten good at discussing some health issues, like infertility or osteoporosis. Breast cancer even has its own Awareness Month. But some topics still feel too awkward to share (uh…incontinence), while others we’ve never even heard of until they happen to us (vaginal prolapse?!).

It’s time we start talking about the uncomfortable stuff, too. To that end, we went looking for some of the women’s health issues that continue to be shrouded in mystery, misunderstanding, or silence, and we found experts to help shine some light. We know what follows isn’t your typical dinner-table conversation. But hey, there was also a time when women didn’t drive around with “I love my ta-tas” bumper stickers on their cars. The more we raised awareness about breast cancer, the less awkward—no, the more empowering—it was to talk about. Why stop there? Let’s talk about all of it.


Hair Loss

Lisa Ishii, otolaryngologist and facial plastic and reconstructive surgeon

Into Thin Hair

According to one study, fewer than 45 percent of women get through life with a full head of hair. For men, balding is difficult but normal—a man might even proclaim that “bald is beautiful!”— but not many women feel that way. In fact, women are more likely than men to withdraw from socializing because of hair loss. “Women should feel reassured that they are not alone and be aware that treatment options exist for them,” says Lisa Ishii. Here, Ishii helps us dispel hair loss fact from fiction.

Hairy brush

Men are more likely to lose their hair than women.
FALSE. Evidence suggests that hair loss is just as common among women as men.

Pattern baldness affects only men.
FALSE. While women rarely go entirely bald, they do experience pattern hair loss, known as androgenic alopecia, typically on the top of the head. As in men, it’s linked to the breakdown of testosterone.

Women’s hair tends to thin, instead of receding like men’s.
TRUE. In female pattern hair loss, hair thins evenly across the top of the head or in a Christmas- tree pattern with the base of the tree at the front of the scalp.

Stemming the Loss

Hair transplants: Not only are hair transplants not just for men, they’re becoming more popular among women, making up about half the procedures Ishii performs.

Medication: Minoxidil is FDA-approved to slow hair loss in women and may help regrow hair, as well. Ishii recommends the 5 percent solution marketed to men, and switching to the 2 percent solution for women if you notice facial hair growth, an occasional—and reversible, thank goodness—side effect of the higher strength.

Platelet-rich plasma therapy: A new treatment where a doctor takes a sample of your blood, separates the liquid component from the cells, and injects the liquid plasma into your scalp. This can slow hair loss, and Ishii has even seen hair regrowth in some patients.

You’re born with all the hair follicles you’ll ever have, about 5 million, including about 100,000 on the scalp.

Wearing hair pulled back tightly can make it fall out.
TRUE. It’s called traction alopecia, and this form of hair loss mainly affects women who wear very tightly braided styles for long periods of time. Scientists think follicle damage prevents regrowth.

Washing, dyeing, or brushing hair too much can lead to hair loss.
FALSE. The main factor in women’s hair loss is aging, with chances increasing roughly 10 percent per decade.

The same treatments work for men and women.
TRUE. With the exception of finasteride, which is FDA approved for use in men only, male and female hair loss is treated the same way. (See opposite page.)

A drop in hormones causes hair loss after menopause.
UNCLEAR. While it’s known that the breakdown of testosterone causes hair loss in both men and women, scientists don’t fully understand the role of hormones in hair loss for either sex.


Postpartum Mood Disorders

Gerald Nestadt and Jennifer Payne, psychiatrists

When Worry Becomes Obsession

Bubblewrapped baby

“What if I smother my baby with a blanket? I’d better check that he’s still breathing.”

Scary thoughts can plague new moms, and while we’ve grown more comfortable talking about postpartum depression, it can be a lot harder to admit we’re having dark thoughts—or even fears that we might hurt our child somehow. “I would say a majority of women have obsessive thoughts about the safety of the baby,” says Jennifer Payne, a Hopkins psychiatrist and director of the Women’s Mood Disorders Center. Payne remembers a trip to Washington, D.C., when she kept worrying that her small daughter might fall onto the subway tracks.

For some women, these normal anxieties can develop into postpartum obsessive-compulsive disorder. “There’s an assumption that it’s a hormonal effect,” says psychiatrist Gerald Nestadt, who specializes in treating OCD, but “there has been insufficient study of this problem.”

Nestadt’s research suggests that about 5 percent of women have an onset of OCD during pregnancy, and almost another 5 percent postpartum. And nearly half the women who already have OCD saw it worsen after giving birth.

Now, it’s perfectly normal to want to check on your sleeping baby. If you’re losing sleep to check again and again, though, that could signal a problem. Many mothers experience postpartum moodiness for a few days, but if you can’t shake that sadness, or if intrusive thoughts are disrupting your daily life, seek help. There are effective treatments for OCD, Nestadt says, and you can put the brakes on those runaway worries.

Hopkins researchers have discovered variations in two genes that predict which women are most likely to have postpartum depression. They hope to develop a simple blood test for pregnant women in the future.

Shades of Postpartum Blue

The “Baby Blues”

Around 80 percent of women have postpartum blues within a few days of childbirth. “I think of it as postpartum PMS,” Payne says—a woman can be both happy and tearful, and feel like her moods are all over the place. Doctors think hormonal swings cause these relatively mild ups and downs, which typically last a few days.

Postpartum Depression

Unlike the relatively mild mood swings of postpartum blues, depression after pregnancy can last and affect daily functioning. Out of 100 pregnant women, 10 or 20 might become depressed, Payne says. The good news: A growing body of research is finding that it’s safe for women to take medications such as antidepressants during pregnancy and lactation.

Anxiety

Anxiety may be even more common than depression after pregnancy and can be present alongside depression. “Anyone who’s been a mother knows it’s a very anxiety-producing time,” Payne says. This can exacerbate pre-existing problems with anxiety or other mood disorders.

OCD

In postpartum OCD, intrusive thoughts and behaviors disrupt daily life and may hamper a new mom’s ability to care for herself and others. Both cognitive behavioral therapy and medications can be effective treatments.

Psychosis

Postpartum psychosis is very rare, affecting only about one or two women out of 1,000 deliveries. Symptoms generally begin in the first couple of weeks after childbirth and can include manic moods and thoughts, depression, delusions, and paranoia. Often this marks the onset of bipolar disorder, and it’s important to seek treatment immediately.


Perimenopause/Menopause

Wen Shen, gynecologist

On average, American women reach menopause at age 51, but it can vary between ages 40 and 60.

Is this crazy PMS or am I already starting menopause?

On average, American women reach menopause at age 51, but it can vary between ages 40 and 60.

Is this crazy PMS or am I already starting menopause?

You’re in your 40s, and suddenly your PMS seems out of control. Your breasts hurt, your periods are less predictable, and your moods are swinging like a trapeze artist. What’s going on? Then you have a hot flash. A hot flash, you think—but I’m only 43! I’m not supposed to hit menopause until I’m 50, right?

Well, it turns out that a lot of us have the wrong idea about menopause. See, there’s this part of it called perimenopause, which starts anywhere from several years to a decade before we stop having periods. It’s during perimenopause that many women have the worst symptoms, which explains how crazy your body can feel in your 40s. Menopause itself is a blip in time: It’s the point when you’ve gone 12 months without a period. When that year has passed, you’re at menopause, and everything afterward is postmenopause.

We asked gynecologist Wen Shen, who specializes in this phase of a woman’s life, to clear up the confusion.

Hot flashes

How do I know if I’m in perimenopause?
During perimenopause, ovarian hormone levels do a roller coaster, and that’s what creates the symptoms. The most common are hot flashes and night sweats, which can lead to mood swings, irritability, and cognitive changes—that feeling of foggy brain.

What happens to my periods during perimenopause?
Many women think their periods will get gradually lighter and farther apart, but it doesn’t always work that way. Sometimes, periods are closer together. I have also had patients go 11 months without a period and then boom, they get a period— and they’re so disgusted. They thought they were done!

If I’m on the pill, how will I know I’ve hit menopause?
I get that question a lot. The average age at menopause in the U.S. is 51. When a patient on the pill approaches that age, I’ll test hormone levels two months in a row to check her level of ovarian function. If the tests show she’s still perimenopausal, she stays on the pill for another six months to a year when we test again. If they confirm she’s postmenopausal, then we can have her stop the pill with fair confidence.

Signs of the Change

Hair loss or growth

Hair may start to thin or to grow in new places, such as the chin. The fix: Scalp treatments containing minoxidil, or hair transplants. For excess hair, see your doctor to check for endocrine disorders; options for removal include electrolysis and laser treatments.

Racing heart

Hot flashes can make the heart beat faster, sometimes causing heart palpitations and dizziness. The fix: Talk to your doctor about whether hormone-based therapy is right for you.

Vaginal pain

Reduced estrogen production leads to thinning of the vaginal wall, making sex painful. The fix: Very low doses of estrogen from an oral pill, or applied directly to the vagina, help rebuild tissue. New laser therapies may help (see below).

Hormone replacement therapy—yea or nay?

If you’re a woman nearing menopause, you’ve no doubt heard horror stories about hormone replacement therapy. HRT came under fire in 2002, when a study found that women using HRT had a 26 percent higher risk of breast cancer and a greater stroke risk. At the time, the most popular drug was an estrogen/progesterone mix, and prescriptions for HRT fell by half. But today, things have changed, Shen says. There are new options that use lower doses than in the past and that don’t combine hormones in the same way. In studies, these new options don’t increase breast cancer risk for most women without a cancer history, and they work well to reduce symptoms.

Mood swings

As hormone levels roller coaster, so do moods. The fix: Hormone therapy taken as low-dose birth control pills, a patch worn on the skin, or other FDAapproved hormones can help. Ask your doctor about your cancer risk.

Hot flashes

These sudden rises in body temperature are caused by the large drop in estrogen during perimenopause. About 75 percent of women get hot flashes, usually for less than two years. The fix: HRT can help.

Bladder problems

The bladder’s mucous membranes become thinner and easily irritable, causing urgency. Also, the microbes in the vagina—its microbiome—can change. Fewer “good” bacteria can cause urinary tract infections. The fix: It’s unclear whether hormone therapy helps, so your doctor might opt for drugs for an overactive bladder or antibiotics to treat infections.

Roller coaster

Why the heck would I laser my vagina?

Thanks to Viagra, men can remain sexually active well into their golden years, but what about women? For years, the only option to combat age-related thinning and drying of the vaginal wall was hormone therapy. But today, vaginal laser therapy is an option. A laser wand inserted in the vagina creates tiny burns—a procedure that sounds scary but is painless, Shen says. This stimulates the vaginal wall to regrow collagen and blood vessels, thus strengthening the vagina and restoring its mucosa, the lining that produces moisture. The catch: Treatments can cost over $1,000, and they’re not covered by insurance—unlike many treatments for erectile dysfunction.


Heart Health

Pamela Ouyang, cardiologist

Her Heart

Her heart

You may have heard that heart disease is the No. 1 killer of women—but did you know that women’s heart problems are often missed or misdiagnosed? Men’s and women’s cardiovascular systems have small differences that can add up to a big challenge for women: Tests and treatments were designed around men, and women’s symptoms often don’t fit the patterns doctors are trained to look for. One recent study found that women have a 50 percent higher chance of being misdiagnosed after a heart attack, and another found women are 60 percent more likely than men to die in the year following an attack. “We don’t fully understand why the heart attack pattern is different in women than in men,” Hopkins cardiologist Pam Ouyang says.

Cause: The most common cause of heart attacks in older women, as for men, is the buildup of cholesterol in the arteries. Stress and depression increase risk and are also more common among women.

Hormone effects: Estrogen may have a protective effect, which could help explain why women have fewer heart attacks than men when they're younger.

During a heart attack: About 60 percent of women have chest pain, but also fatigue and disturbed sleep in the days before an attack, and cold sweats, dizziness, and weakness during. Women also have pain in the neck, jaw, back, or abdomen.

Diagnosis: An EKG test, but for women, some doctors now add an echocardiogram or radionuclide imaging to get a better view of coronary arteries.

Heart disease is the leading cause of death worldwide for both men and women.
His heart

His Heart

Cause: Most sudden cardiac events happen in men, and half of men who die suddenly of coronary heart disease had no prior symptoms.

Hormone effects: Hopkins research suggests that male hormones may increase heart attack risk for men, an effect that tapers off as hormones drop with aging.

During a heart attack: What have long been considered the “classic” signs of a heart attack are common in men: chest pain and radiating pain in the neck, back, and arms.

Diagnosis: Blockages in the coronary artery are usually diagnosed by EKG monitoring during a stress test, such as walking on a treadmill.

Osteoporosis and Your Heart

“The best time to build bone is the teens,” says Ouyang, through a calcium-rich diet and plenty of exercise. As we get older, those have less effect for preventing osteoporosis, and many women take calcium supplements in the hope of staving off bone loss. Some studies suggest, however, that calcium supplements are associated with a higher risk of heart attacks. The jury is still out on that connection, Ouyang says, but women generally shouldn’t take more than a multivitamin’s worth of calcium per day without first talking to their doctor. (A typical multivitamin has 300– 400 milligrams.) You can also help keep the bone you have by doing weight-bearing exercises such as jogging, aerobics, and weight training.


Prolapse and Incontinence

Victoria Handa, obstetrician/gynecologist

Whoa! My uterus could fall out? ...

You feel something strange in your vagina, and reach down to find—OMG—something is sticking out. What’s happening?

It's called vaginal prolapse. The uterus slips out of place and falls into the vagina, taking the cervix with it. Sometimes, the bladder or rectum can follow. About one in 10 women have surgery for this condition, yet many of us haven't heard of it.

Sometimes a prolapse can feel like you’re sitting on a small rubber ball, or you may just feel pressure in your pelvis. And it happens in stages over time; often women have no idea their uterus is out of position unless a gynecologist points it out. Vaginal prolapse can be shocking, but it’s rarely painful—and it’s treatable, says Hopkins gynecologist Victoria Handa.

shocked friends

Do patients know about prolapse?
It’s common for women not to know. Especially older women who weren’t comfortable talking about their bodies.

Can we predict who will have a prolapse, or prevent it?
Prolapse is more common in women who have given birth, but right now we can’t predict. You’re more likely to have a prolapse if women in your family did. Kegel exercises haven't been shown effective as prevention but are effective as treatment if you’ve been diagnosed.

How do you treat a prolapse?
We have a number of safe and effective surgeries. It depends on the type of prolapse, but many include a hysterectomy. For that reason, we usually avoid surgery until women are done with childbearing. If a woman is still having children, we usually recommend a pessary, which is a small plastic device inserted into the vagina to support the pelvic organs. In surgeries, we can use ligaments from the woman’s own body to support the organs. Sometimes a mesh is used.

What about the scary TV ads from lawyers about mesh?
Mesh has been used without problems in incontinence surgeries since the early 1990s. Device companies started making slings for prolapse, but prolapse is biologically different. The FDA says these products should go through more testing.

... and other pelvic calamities

leaky faucet

Here’s the thing: Urinary incontinence isn’t an old person’s problem. It’s twice as common in women as in men, and about 15 million American women have stress incontinence (the kind that makes jumping or sneezing hazardous). Though it often crops up in middle age or after childbirth, it may be more common in young women than we thought. An Australian survey found one in eight women between 16 and 30 has had incontinence. It’s a fact of life for many, and it’s nothing to be embarrassed about. Here are a few common urinary problems for women, and how you and your doctor can tackle them.

More than 25 million adult Americans have some form of urinary incontinence, and about three-quarters of them are women.

Causes and Cures

Stress incontinence

Cause: Weak pelvic floor muscles can’t withstand sudden abdominal pressure on the bladder, caused by movements such as sneezing or laughing.
Cure: Depending on severity, women can try exercises to strengthen pelvic floor muscles, a pessary, or surgery that uses a sling to support the urethra.

Urgency incontinence

Cause: After menopause, a drop in hormones causes the mucous lining of the bladder to thin and become easily irritated. This can lead to urgency, the sudden strong urge to urinate.
Cure: In addition to treatments for stress incontinence, your doctor may suggest bladder training (upping the time you can “hold it”), bladder-control medications, or electrically stimulating the nerves that control the bladder.

More frequent UTIs

Cause: If you’re getting urinary infections more frequently as you get older, it may be because the community of microbes living inside you, known as the microbiome, has changed.
Cure: Low-dose estrogen creams applied to the vagina may help strengthen urinary tract tissue and boost infection- fighting proteins.

Flowers in a vase
Illustrations Eléna Potter

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