Here's how Prof. Graziottin answers this question from her patients:

First, improve your lifestyles: the more appropriate and consistent they are, the stronger the investment you will personally make in your longevity in smart health!

Physicians, you should:

• Always take a very accurate family and personal history, to evaluate leading symptoms and signs the menopause is causing, the leading vulnerabilities and the few major contraindications (to hormone replacement therapy, say, hormone replacement cancer breast, endometrial and ovarian cancer, thrombophlebitis/thrombosis).
• Second, physicians should carry out a comprehensive physical examination, as I do with my patients, including thyroid, breast, abdomen, gynecological and pelvic floor examination, plus blood pressure, body weight, height and abdominal circumference.
• Third, important to carry out pelvic ultrasonography, pap-smear and/or HPV test, or ask for mammography and bone mineral density (BMD), if the woman is older than 50, or earlier if there is a clinical indication for that. For example, bone mineral density could be appropriate in individual cases, in case of premature ovarian insufficiency, persisting binge eating disorders of restrictive type up to frank anorexia, or cancer treatment with chemotherapy and/or pelvic or total body radiotherapy in also in case of NON-hormone dependent cancers.
• If a hormone replacement therapy is indicated, then it can be tailored according to the woman’s needs in terms of:
  • types of hormones
  • dosage
  • route of administration
  • regimen: cyclic combined or continuous combined, 

A well-tailored menopausal hormone therapy (MHT) improves the level of health in every organ and tissue: from brain to cardiovascular system, from bones to muscles and joints, from skin to nails and hair, from genitals to bladder. 

MHT improves the gut, the vulva, and vaginal microbiota and microbiome as well, the best secret directors of our health, which have major receptors for sexual hormones. A positive dynamic eubiosis is back, for the best of our systemic health, general and intimate health.

New solid data indicated that very positive health advantages are there also for women who continue far after 65 years of age, always in synergy with healthy lifestyles.

Key point: menopausal hormone therapy replaces the lost hormones, but they work at their best if you take full responsibility for your own health. No alibi, no excuses, please!

Lifestyles are key! 

Related content

^BMI-24.55

Here's how Prof. Graziottin answers this question from her patients:

Your body is telling you the truth: your ovaries are losing their last oocytes, say the reproductive female cells, and are losing their follicles, say the cells that nourish the oocytes and produce estradiol, estrogens, and progesterone.

These symptoms tell you that the three major consequences are impending:

• First, loss of menses = menopause
• Second, loss of fertility (unless oocytes preservation, with cryo-conservation, has been carried out in the earlier fertile years).
• And third, loss of health: because these symptoms (hot flashes, insomnia, swollen belly, pain in your joints…) are a real “cry for help”. Your body is asking for help because it wants to have back the hormones lost with ovarian exhaustion. For example, the belly is getting “swollen” because the loss of sexual hormones causes a major dysbiosis in the gut, with reduced biodiversity and an increasing number of gas-producing bacteria.

In parallel, it causes vulvar and vaginal dysbiosis, with the loss of our friend Lactobacilli, increased biodiversity in the vaginal microbiota and microbiome and an increasing number of bacteria like the Gardnerella Vaginalis causing bad smell. Also, this increases the vulnerability to contaminants from the bowel like Escherichia coli

Remember: women are never too young to get menopausal. Therefore, listen carefully to those symptoms even in adolescent girls! A woman can be young and very beautiful, and yet have a very early premature ovarian insufficiency, for a number of reasons (genetic first, autoimmune if she has celiac disease or other autoimmune diseases, after removal of an endometriotic cyst in the ovary or mono-lateral ovariectomy for endometriosis or chemo or radiotherapy.

Related content

^BMI-24.55

Here's how Prof. Graziottin answers this question from her patients:

Use condoms consistently, from the beginning of intercourse, in every sexual intercourse with no exceptions, unless you are looking for children or you are in a stable trustworthy non-promiscuous relationship. 

What’s the point? Sperm has a pH of 7.39. When the quantity of sperm per ejaculation is abundant (say 6-7 ml instead of the normal 2-4), the vaginal pH increases temporarily, predisposing to vaginal dysbiosis and increased growth of anaerobic bacteria such as the Gardnerella Vaginalis, and this is the germ that produces bad smell, bad scent. If intercourses are frequent, then this clearly contributes to persistent vaginal dysbiosis, leakage and bad odor. Condom use is an easy and very effective protective measure.

Key message: consistent condom use is also the very first protection against sexually transmitted infections and diseases.

So, sex can be enjoyed frequently, with lots of pleasure and joy, if consistent condom use becomes your best self-protective strategy.

Related content

^BMI-24.55

Here's how Prof. Graziottin answers this question from her patients:

Here is a list of questions you could ask your patients in order to provide them with the best possible answer:

• First, how old are you? The hormonal status has a major role in modulating the biological basis of sex drive. The hypothalamic amenorrhea, say when you don't have period because of stress, you don't have period because you're lactating, or menopause, are three conditions with low sexual hormone levels that have a major role in killing your sex drive.  And also check your thyroid hormones as well.
• Second, are you really feeling stressed? Stress is another major enemy of sex drive. Because we have a peak of cortisol due to stress to face enemies or difficult situations, also emotional, and this will cause a systemic, say all your body will be inflamed with neuroinflammation, say in your brain, and this causes depression, a major enemy of sex drive. But also irritability, mood changes, and a frank depression that will cause a loss of sex drive. But also stress is the major etiology of gut dysbiosis. Besides, and this is true, and you know that, stress is the major killer of our vital energy. Say we have no energy; we have no possibility to enjoy sex drive and have thrilling sex.
• Third, how’s the quality of your sleep? Because sleep is a major protector of your vital energy and also of your sex drive. When sleep is inadequate in quantity or quality, another major enemy of sex drive is dramatically in play.
• Another question: how’s the tonus, the contraction, of your pelvic floor muscles? Do you complain of vaginal dryness or sexual pain at the entrance of the vagina? This is clear. If you have a tight pelvic floor and you have pain at the beginning of the intercourse, this will kill your sex drive because to have no more sex drive is a self-protective measure to prevent other painful intercourse. So your physician should check the pelvic floor and recommend physiotherapy. 
• And then, very important for every patient and with doctors as well: What are your lifestyles? How’s your diet? Do you do any physical activity, at least brisk walking in the morning, to steam off your stress, your irritability? Are you overweight or obese? Do you drink, smoke or use drugs? Do you have any bowel symptoms, diarrhea, constipation? Why that? Because chronic stress may affect your gut microbiome and cause gut dysbiosis with a lot of consequences on the energy level, your sense of well-being, the smile to life and to sex or not.

Check the hormones and recommend, if feasible, more time to sleep and recharge the vital energy. Recommend daily brisk walking outdoors in the morning, also to go to work or to accompany children to school. 30 minutes is 1/48 of the daytime! And this is an effective money and time-saving good start to reduce physical and emotional stress, from scratch, so to speak.

Recommend a better diet and no alcohol: apparently it relaxes, but it is a powerful killer of sex drive, also through the gut dysbiosis it provokes, in parallel to the damage to the central nervous system. And also recommend a committed program to exercise and lose weight, to improve self-image and self-perception.

In parallel, ask about the quality of the relationship? If the couple has a major crisis, sex drive loss is the first symptom the woman complains of.

Related content

^BMI-24.55

Here's how Prof. Graziottin answers this question from her patients:

Listen to the TIMING of the itching. If itching peaks at night, we have two major causes:

• First, bowel parasites, they could be in play because they migrate through the anus in the perineum at night to deposit their eggs. They are more frequent in children and adolescents, with rare cases in adult and elderly women. But the search of parasites is key in the feces to confirm the diagnosis. The search of the parasites in the feces will confirm the diagnosis. Clinical examination, a vaginal swab with the exam of the secretion at the microscope in the office or a culture test can confirm the diagnosis.
• The most frequent etiology of itching at night with increasing age is the so-called vulvar lichen sclerosus. It is present also in children and adolescents, but it increases in prevalence with increasing age. 
• It is an autoimmune disease, what does it mean? Our immune system attacks the vulvar tissues in all their components, with progressive thinning and whitening of the vulvar skin, fusion of the labia, destruction of the tissue, and damage to the nerve terminals, the nerve endings. This is responsible for the itching feelings.

When the itching is also frequent during the day, think about the Candida infection and important to an aberrant response of our immune system, abnormal response, to the candida antigens. Because this causes itching, and again, we need a clinical examination of the vaginal swab with the exam of the suppression at the microscope of the office and a culture that can confirm if really a candida infection is in play in causing this itching day and also at night.

The predisposing factors include:

• First, an inappropriate diet rich in sugar: That's why we strongly recommend a sugar-free or almost-free diet. Why that? Because sugar gives a lot of energy to the candida and she will aggress us with much more intensity. But also because sugar causes gut, vaginal and vulvar dysbiosis.
• Second, we may have hyperactivity of the pelvic floor, too tight on the pelvic floor, and this predisposes to microabrasion that increases the probability of the aberrant immune reaction to candida antigen.
• And then, vulvar and vaginal dysbiosis worsens the infection and predisposes to recurrences, in spite, very important, of both oral and topical antimycotic treatment.

^BMI-24.55

Here's how Prof. Graziottin answers this question from her patients:

First of all, every woman should know that Uropathogenic Escherichia Coli (UPEC) is a true “terrorist inside the bladder wall”. Why? Because they are there even when the urine exam is negative. So you have the enemy inside the bladder wall. This will also cause a progressive inflammation of the bladder wall. So first you have the cystitis and then you have persistent pain in the bladder. And then this may lead to interstitial cystitis. So it's a very serious condition to block the Escherichia coli, so to say, in the first episodes of cystitis.

There are three major “triggering conditions” for the cystitis and urinary tract infection: 

First of all, and women know that very well, intercourse may “traumatize” the urethra, more so when the woman has very tightened pelvic floor muscles. Cystitis appears 24 to 72 hours after intercourse. 
When cystitis is the first symptom women complain of, 60% of women complain also of pain at intercourse at the entrance of the vagina, squeezed, so to say, by the tightened pelvic floor muscles.

• Second, the second etiology of recurrent cystitis is acute diarrhea or constipation because this increases the possibility that contingent plotons, so to say, of Escherichia coli, your pathogenic, cross the bowel wall and through the lymphatics or the blood, aggress the bladder.
• The third and very, very important is the environmental cold. Environmental cold increases the aggressiveness of Intracellular bacterial communities. Why? when a rapid and marked difference of temperature – between, for example, the beach in hot summer, and the bar when you go to take a beer or a water. The sudden difference causes rapid dysbiosis in the gut and this increases the likelihood that your pathogenic bacteria cross the bladder wall and aggress via the lymphatics of the blood the bladder.

And at the same time, this increases the aggressiveness of the intracellular bacterial communities. So this double attack increases the likelihood of a “cystitis a frigore”, said caused by the cold, as the old physicians, Latin physicians, used to say 2,000 years ago.

To prevent recurrent bladder infections the winning strategy is to avoid antibiotics, except in severe cases of hemorrhagic cystitis, as they worsen gut dysbiosis, increase antibiotic resistances, worsen irritable bowel syndrome and the vulnerability to Escherichia coli attack. 

A preventive approach with phytotherapy can be made including D-mannose and red-current at nighttime, may help. 

Oral and vaginal probiotics may contribute to protecting the bowel, the vagina and the bladder!

And don't forget to recommend the relaxation of the physiotherapy for the pelvic floor.

Relate content

^BMI-24.55

Here's how Prof. Graziottin answers this question from her patients:

First of all, Urinary Tract Infections (UTI) are caused mostly by Uropathogenic Escherichia Coli (UPEC). What does it mean? The name is clear, this germ can attack the bladder, the urethra and also the kidney, causing very very serious infections of increasing severity 

This UPEC, Uropathogenic Escherichia Coli, is a member of a big family, more than 100 brothers, so to speak. They live very happily. They live happily in our gut without causing any harm. However, when the UPEC reaches the urinary tract, it can attack the urinary cells (say the urothelium and later the bladder and the urethral wall) with a very specific damaging strategy.

What we know now is that the UPEC can attack the bladder via three major pathways:

• The first is via the perineal area, attacking the vagina first, and the bladder second. This pathway is more frequent in situations when the woman has low or no estrogens, for example, when she has no periods because she has psychological emotional problems or eating disorders, or when she is lactating, or after the menopause. In all these three conditions, where the level of estrogens is very low in the tissue, we have a major change in the microbiota in the vulva, in the vagina, and in the bladder, and this microbiome becomes more vulnerable to the attack from the Escherichia coli uropathogenic.

• Second, the Uropathogenic Escherichia coli, which is specialized in attacking the bladder may attack via the reactivation of the so-called “intracellular bacterial communities” (IBCs). What does it mean? During the first or second or third attack of cystitis, Escherichia coli takes away the coat, attacks the cells that line the inner part of the bladder and the urethra, enter into the cell, and become resident. These become resident intracellular bacterial communities that are almost dormant, but become very aggressive, for example, 24-72 hours after intercourse, causing post-coital cystitis. 
• They can also attack the bladder through the bowel wall, They can attack through the bowel wall when the woman complains of irritable bowel syndrome, diarrhea, constipation, food intolerance to lactose or gluten, or after antibiotics. In all these cases, we have gut dysbiosis, and because we said this will damage also the wall of the bowel and cause the so-called leaky gut syndrome, say, we have a passage of germs through the bowel wall, and this via the lymphatics or the blood can attack the bladder and the urethra.

So, three major pathways, the first through the perineal area, attacking first the vagina and then the bladder, this is particularly relevant when estrogens are low. Second, through the reactivation of Escherichia coli already inside the bladder wall, and third, through the bowel when we have gut symptoms.

A good collaboration with a competent gastroenterologist is, therefore, key to addressing this component of the infection of the bladder stemming from the bowel.

Related content

^BMI-24.55

Here's how Prof. Graziottin answers this question from her patients:

The healthy vulva and vagina have a very delicate scent and taste, thanks to their natural microbiota in eubiosis, say, in a very good dynamic equilibrium and health.

In this condition, the vagina has a prominent family of lactobacilli, say, 80% Crispatus, Gasseri or Jensenii, and a natural perfect acidity with a pH around 4.

If the vagina secretions smell bad, like the smell of a spoiled fish, the cause is an increased proliferation of a microorganism called Gardnerella vaginalis, which is normally present in the vagina but in very small percentages. What's the point? The percentage increases with the increase of the vaginal pH.

This means that the normal acidity of vaginal secretions, which in the fertile age is perfect at around 4, increases to 5 or more for a number of reasons:

• First of all, gut dysbiosis, because they communicate with each other.
• loss of sexual hormones, particularly after menopause,
• or unprotected sex, just to mention a few, and the most frequent.

When the pH becomes 5 or more, the likelihood of bad scent increases. To maintain the low percentage of Gardnerella, typical of a dynamic eubiosis, we should guarantee the normal level of estrogens in the vaginal, maintain the menstrual cycle very regularly, and have a very healthy gut and vaginal microbiome.

Related content

^BMI-24.55

Here's how Prof. Graziottin answers this question from her patients:

The cleaning should be done daily, ideally after bowel voiding, using the hand from front to back. Prefer a gentle, soap-free cleanser able to protect selectively the intimate vulvar flora and protect indirectly the vaginal microbiota and microbiome. 

In couples that are loyal to each other, and with appropriate personal hygiene, washing the genitals after sex is not recommended. It is recommended when the couple likes anal intercourse (that should always be done with a condom!) for two main reasons :

• To protect the spreading of the colonic bacteria into the perineal area and spreading them to the vulva, changing aggressively the vulvar microbiome
• and also to prevent sexually transmitted infections.

If you change partners often, use condoms consistently, from the beginning of the intercourse and in every type of intercourse. Because this is the safest defense line for keeping your secret garden clean and happy, i.e. to protect your vulvar and vaginal microbiota at your best.

In short, what I say is that to prevent the invasion of pathogens and germs is the first logical act of self-protection because you value. Opposite to that and beware this point, washing the genitals, the vulva, the vaginal, doing the vaginal douching after intercourse, beware, after unprotected sex, it is a dangerous illusion of self-protection. Why is that? 

In too many cases, the damage is secretly done, particularly when the partner is a “healthy carrier”,  What does this mean? It has no symptoms nor signs of infection and yet it has, for example, the papillomavirus inside the sperm and this will be transmitted to you. Washing means nothing. So, the first line to protect yourself consistently is to use condoms in every intercourse with every partner and in every type of intercourse. This will promote and protect yourself, your whole health and the vulva and vagina microbiome effectively and consistently. You value. Do it.

Related content

^BMI-24.55

Here's how Prof. Graziottin answers this question from her patients:

• Periods should not hurt much. Usually, in most women, they cause a mild discomfort that does NOT interfere with daily life and personal activities (school, sports, friends, work, leisure). Important! We do have friends microorganisms also within the uterus. Today we talk about the endometrial microbiome and now we understand that the health of this microbiome contributes to painless, so to say, periods, whilst a dysbiotic microbiome may be a contributor also to painful periods and the progression to endometriosis.
• First sexual intercourse can be painless in some women, when the hymen is naturally very thin and elastic we talk about a “complacent hymen” or it has been gradually dilated with the finger during foreplay. In the majority of women, the first intercourse causes a mild pain, that usually fades away after two or three intercourses.

In less frequent situations, the first intercourse is extremely painful and some women cannot accept the penetration at all. In this case, we have a very tight and tightened pelvic floor contraction and this is responsible for the sexual problem called vaginismus, causing sexual pain. In this case, if the woman keeps on, and a couple, keeps on trying to have intercourse, this will damage the mucosa, cause dysbiosis of the local microbiome and this is another cause of vestibulodynia, say, this burning pain that women will have not only during the attempt of penetration but also afterwards.

This requires a very rigorous medical treatment with a competent sexual medicine approach.

So, sexual pain is never in women's head, it has a very solid biological basis, more solid when pain is excruciating.

When pain during periods, dysmenorrhea, interferes with daily activities, it is worth medical attention the sooner the better. It may be the first sign of endometriosis that is still below the visibility threshold of the current imaging diagnostic techniques. 

Vaginismus, a sexual disorder characterized by the phobia of penetration, must be considered when pain is excruciating, up to prevent penetration. The phobia is associated with a variable degree of defensive tightened contraction of pelvic floor muscles. The repeated attempts of penetration may damage the vestibular mucosa contributing to vestibular pain up to vestibulodynia.

Key point: sexual pain is NOT normal. It should be competently diagnosed and treated, the sooner the better.

Related content

^BMI-24.55