Hot flashes, brain fog, frisky older women: Q&A with a sexual health expert

Robyn Faye, an OB-GYN at Jefferson Abington Hospital, has been tapped by Jefferson Health to become codirector of its new menopause center, slated to open later this year.

Faye, a certified menopause practitioner, gave up obstetrics more than a decade ago to focus on menopause, sexual health and gender-affirming care. In 2015, she became only the second medical doctor in Pennsylvania to be certified as a sex counselor through the American Association of Sexuality Educators, Counselors and Therapists (AASECT).

Faye said she decided to go back to school to become a sex counselor, studying at the University of Michigan, because many of her patients struggled with intimacy. "I realized that I had nobody to ask questions of when it came to sexual health," Faye said.

Faye spoke to The Inquirer about the hormonal lava lamp within us, enjoying intimacy as we age, and the advice she once got from the late sex therapist Ruth Westheimer, "Dr. Ruth."

Women with symptoms—hot flashes, night sweats, brain fog, mood swings and insomnia—will often complain about 'going through menopause,' but that's not really accurate. Can you explain?

Menopause is when you don't have your period at all for 12 months. Menopause is only one year. So it's a misnomer to say, "I'm in menopause."

Most people will come into my office during perimenopause, which typically starts five to 10 years before menopause. That's the transition time, which is that rocky time when your hormones are like a lava lamp. They're all over the place, and that's the worst time. The average age that perimenopause begins is 51 or 52, but people can start having symptoms even earlier.

What is hormone replacement therapy (HRT)?

We actually call it hormone therapy because we are not replacing the exact doses of hormones that you had when your ovaries were working at full capacity as a young woman. Hormone therapy is estrogen and progesterone. The estrogen that we use most commonly is estradiol, which is one of the estrogens that your ovaries used to produce.

We use a natural progesterone called Prometrium, which is made from peanuts, unless someone has an allergy. We also use testosterone, a sex hormone that is produced by your ovaries and adrenal glands and drops off as we age. Initially, when we start hormone therapy, I don't start with all three—estrogen, progesterone, testosterone.

I see how someone is doing symptomatically by just doing estrogen and progesterone. The primary reason for hormone therapy it is to help with vasomotor symptoms, like hot flashes and night sweats.

Do you recommend it? Some women worry about increased risk of breast cancer

You have had estrogen your entire life. So what is the risk? Studies found one additional case of breast cancer for every 1,000 women treated per year, and three additional cases of breast cancer when you use it for five years. The risk is similar in terms of two glasses of alcohol a day and low physical activity.

The truth of the matter is, the risk is very low. Absolutely, the bottom line, is that it makes perfect sense during the 10-year window that begins when someone starts having irregular periods. For quality of life, absolutely it is worth using.

Does it help with brain fog? How can you tell the difference between brain fog and dementia?

Hormone therapy is not recommended in order to prevent or decrease a decline in cognitive function. But if somebody is actually saying to me, "I'm having all these other symptoms, including brain fog," I have found there to be success in helping their symptoms.

But if their only symptom is brain fog and there's a family history of dementia, I have more concern that there might be something else going on. I may try hormone therapy with them for a three-month time period, but if it doesn't get better, I'm sending them off to a neurologist.

What do you recommend for women who suffer from vaginal dryness?

We talk about moisturizing, and we talk about lubricating. Once you go through menopause, you lose that natural ability to moisturize. We have over-the-counter moisturizers, and prescribed vaginal estrogen, which is the best because it's also been found to decrease the risk of urinary tract infections (UTIs).

Lubricants, which are totally different, can prevent painful intercourse. Lubricants should be either water-based or pH-balanced. You've got to look at the label. I have to give them a whole lecture about it. I say to them, "Who's buying your lubricants?" and they go, "Oh, my husband," and I go, "Do you have them buying your bras?" Yes, he went to chemistry class, but he doesn't know what the pH-balance of the vagina is. If he does, mazel tov, but most times he doesn't.

What do you think of the recent study showing toxic metals in tampons? Should women stop using them?

I'm really curious about this. Most of my patients are using menstrual cups, so they're not using tampons. It's really scary, but like with every study, there has to be more studies done. I may tell people to use tampons less, like maybe only on heavy days. I don't think straight-out I'm going to say, "Oh my God, everybody stop using tampons." It definitely needs more study before we start to panic.

You specialize in women in transition. Can you elaborate?

I see trans people in my office. I offer gender-diverse individuals hormone treatment. I prescribe sex hormones and provide gender-affirming care. It's medication for female-to-male hormone therapy. There's different ways of doing it—I can prescribe an oral pill, an injectable, an implant or a patch. Not everyone has top and bottom surgery so they need to continue to be seen by a gynecologist even though they are now a male.

I continue to perform breast exams and annual exams with Pap smears and order mammograms, when needed. We also discuss safe sex and contraception. I advocate for inclusive, thoughtful and affirming care for transgender patients. Patients need to be able to come in and ask questions and not feel that anybody's going to judge them.

Tell me about that time you jumped on a Zoom call with 'Dr. Ruth'

I had emailed her to ask her a question, and she was sweet enough to Zoom with me in May 2020. The question was something about sexual dysfunction and how to talk about sexual health with my older ladies. I have ladies in their 80s who come to me from The Villages in Florida (a 55+ community known for, ahem, romance).

They come up every six months and they're having the best sex ever. But one of them was having issues and she was a little bit more prudish than her friends. I figured, "You know what? The best person to ask is Dr. Ruth." She was great and said talk to them like you talk to your 60- and 40-year-olds.

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