For many women, choosing the right gynecologist becomes more important than ever after age 40. As a woman approaches the onset of menopause, it is crucial to find a doctor who will be sensitive to the physical and psychological changes she is going through. And in this era of controversy and confusion regarding the best options to protect a woman’s health after menopause – as well as reduce hot flashes and other uncomfortable symptoms – finding a doctor who is well-informed and willing to carefully explore treatment options is a must.
If you already have a gynecologist you can rely on, consider yourself lucky. If not, the best way to find someone is through referrals by a family physician or a friend. “Ask for the names of doctors who have worked extensively with patients in, or nearing, their post-reproductive years,” suggests Jody Blanco, M.D., a New York City gynecologist. You may end up visiting several doctors before you find one who feels right for you.
Like any patient visiting a physician, the over-40 woman should expect her gynecologist to take a medical history. The doctor should ask about general health habits (diet, exercise, whether you smoke), as well as specific conditions in your personal and family history. He or she will also want an obstetric history (including any past abortions), and some basic information about your sex life: whether you are currently sexually active, whether you’re monogamous, and what kind of contraception, if any, you are using.
If you are over 40, it’s a good idea to keep a “period” calendar, and to share that information with your gynecologist: Menstrual changes, such as missed periods or a heavier-than-usual flow, may be the sign of approaching menopause or a health problem.
“With older patients, I pay more attention to any abnormalities of the menstrual cycle,” says Jonathan Scher, M.D., a gynecologist and assistant professor of ob-gyn at Mt. Sinai School of Medicine in New York. “At this age, there’s a greater likelihood of a tumor or some other condition that requires treatment.”
Sometimes, menstrual irregularities don’t signal anything significant, but a competent gynecologist will always try to determine the cause. “Depending on the circumstances, I might do a sonogram to look inside the uterus and see if there are polyps or fibroids,” says Dr. Blanco. “Or I might do a hormone test to see where the patient is in relation to approaching menopause.” Since a gynecologist is often the only doctor a woman sees, a thorough physical check-up is essential. The gynecologist should check your heartbeat, lungs, blood pressure, and cholesterol level; examine your abdomen (for possible masses that might indicate a malignancy), and do a breast exam, pelvic exam, and Pap smear (to detect abnormal cells in the cervix). Women who are unsure of their sexual partner’s health status should also ask to be tested for sexually transmitted diseases, including chlamydia and HIV.
Once a patient reaches her forties, her gynecologist also needs to perform a rectal exam and check the patient’s stool for blood as part of the routine check-up. This is performed with the insertion of a gloved finger; some women may find the procedure a bit uncomfortable, but done properly, it should not be painful.
How often should a woman over 40 visit her gynecologist? Some doctors say that once a year is fine, as long as the patient is healthy; others suggest biannual check-ups. “I encourage older patients to come in every six months,” says Dr. Scher. “The risk of certain diseases increases after 40. And if something develops, like ovarian tumors or breast lumps, a year is a long time to wait.”
You should schedule an appointment as soon as possible if you experience any of the following symptoms: bleeding between periods, excessively heavy menstrual bleeding, painful intercourse, chronic pelvic pain, and lower abdominal pain and/or swelling. This last symptom, notes Dr. Blanco, “is easy to overlook. The patient might just think she is getting fat, but it could actually be a sign of ovarian cancer or enlarged fibroids.”
Menopause and Sex
Menopausal patients who are troubled by symptoms like hot flashes, sleeplessness, or vaginal dryness need to discuss the problem with their gynecologist. Luckily, there is an ever-expanding range of hormonal and non-hormonal treatment options. A good gynecologist will take into account not only a patient’s medical history, but also her concerns about what treatment feels right for her.
These days many women are particularly concerned about hormone replacement therapy (HRT): A recent large-scale study, the Women’s Health Initiative, indicated that women who take Prempo, a popular combination of estrogens and progestin, had a slightly higher rate of heart attacks, strokes, and breast cancer than those not on hormones. The study’s results contradicted the medical community’s previous widely held belief that HRT protected the heart – and have led many patients to discontinue hormone therapy.
“Some of my patients just don’t feel comfortable taking hormones,” says Dr. Shelley Kolton, M.D. of Downtown Women’s Ob/Gyn Associates in New York. “So, I talk with them about herbal remedies that are effective, and if necessary, refer them to a competent alternative practitioner.”
Still, for many other women, the benefits of HRT outweigh their concerns about risk. If a patient does want to consider hormone replacement therapy, her doctor should thoroughly discuss its risks and benefits, providing her with ample information to make a decision.
Sex is a frequent concern among menopausal women, and it’s important for a patient to share any sexual problems with her doctor. Vaginal dryness is probably the most common sexual symptom of menopause, but there are others. Some women experience vaginal shrinkage that makes intercourse a painful ordeal. Some undergo a drop in libido, causing them to lose all interest in sex.
A conscientious doctor will work with the patient on solutions, which can range from suggesting a vaginal lubricant to recommending hormone therapy for severe vaginal problems or diminished sex drive. Dr. Kolton, for example, has successfully prescribed hormone therapy combining estrogen and testosterone to restore libido in some menopausal patients.
Dealing with the psychological component of menopause is also important. Sometimes a woman’s loss of sexual interest during menopause has less to do with hormonal changes than it does with emotional factors, notes Dr. Scher. “Perhaps a woman is feeling less sexy because she feels like she is no longer desirable. Maybe her husband’s libido has somewhat diminished with middle age, and he is not showing any interest.”
In such cases, Dr. Scher often refers the patient, and her partner, to a sex therapist who can help them sort out their personal issues. But of course, a doctor can only help if the patient feels comfortable enough to broach such issues in the first place. “Every patient wants a compassionate doctor, someone she can open up to,” he says. “As a practitioner, you’ve got to be very supportive.”
And if your gynecologist isn’t supportive? Then it’s time to find a new gynecologist.