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Your doctor may help you live longer, but has likely never asked if intimacy still matters to you. In this episode, Michael Reed, a board-certified obstetrician-gynecologist, certified menopause practitioner, and fellowship-trained cosmetic gynecologic surgeon, explains why so many women are never given the chance to raise sexual health concerns with their physician. You will hear why medicine taught women that these topics are off limits, why doctors trained to fix what is broken often miss what a patient actually wants, and the plain-language questions any clinician can start asking. You will also hear the small, concrete steps Reed recommends, from handing a patient a mirror to understand her own anatomy, to prescribing vaginal estradiol for dryness and recurrent infections, to knowing when to refer. This episode is based on his article “The exam question OB/GYNs were never taught to ask,” published on KevinMD. Press play to hear the one question physicians were never taught to ask, and the simple changes that can help women live well, not just longer.
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Transcript
Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today, we welcome Michael Reed. He’s a board-certified obstetrician-gynecologist and a cosmetic gynecologic surgeon. Today’s KevinMD article is “The exam question OB/GYNs were never taught to ask.” Michael, welcome to the show.
Michael Reed: Well, thank you for having me. It’s an honor and a pleasure to be here on your platform and to share some of my thoughts. I’m excited to be here, and thank you for having me.
Kevin Pho: Perfect. So let’s start by briefly sharing your story, and then why you decided to share this particular article on KevinMD.
Michael Reed: So my background is that I’m an obstetrician-gynecologist by training, and I have been ever since I graduated. But I’ve moved a little bit lateral to that. Now I do what we call cosmetic gynecology. Cosmetic gynecology is basically a division of medicine that provides a safe place, a judgment-free place, for women to come talk about the things that really matter to the modern-day woman as it pertains to women’s sexual health.
And so that’s where my heart lives. That’s where my practice lives, and that is about changing the landscape for women and starting to bring women’s sexual health to the forefront.
Kevin Pho: And in terms of the most common questions and cases that you see every day, what would be examples of some of them?
Michael Reed: What I see on a daily basis is women’s experiences. Their experiences vary. They can vary from personal experiences wearing clothes, or being able to be intimate with the lights on. It could be an experience with their partner. They’re not able to share and be as intimate as they would like to because of pain or lack of structural support. Or I hear from women who are suffering because they are having pain on a day-to-day basis, and so they’re looking for ways to restore and recover.
And so what I really do is listen to what the patient’s desires are and then try to figure out solutions, because I feel that right now in medicine, we look to fix things that are broken, and we’re not looking at things through the experience of the person. We all want to live longer, but we want to live well while we live longer. And so that’s the place that I sit in, and that’s what I hear on a day-to-day basis: “Help me with this experience. Nobody is listening. It is silent in the exam rooms. I can’t even bring it up.”
And that’s what made me want to get on your platform and have the opportunity to share some thoughts that I have about what I’m seeing on a day-to-day basis. And so that’s what brought us together, Kevin: the question that we as physicians do not ask. Is intimacy still a meaningful part of your life? I think if we asked that question, we would learn a whole lot, and we could change a whole lot. And I think that women just haven’t had that opportunity given to them, and I think that a lot of physicians feel, “Well, I don’t hear that in my exam room. This surely can’t be going on.” Well, the problem is that we’re not providing the judgment-free space for the patient to ask that question.
Medicine has taught women over the years, over decades, that certain topics are off limits. You don’t bring them up. We can help you with specific problems, whether it’s uterine fibroids or cervical dysplasia. We can help you deliver a healthy baby. We can even come up with good preventive measures to help you live longer, but it doesn’t mean that they’re living better. The things that they’re missing are the reasons why we are living: to be a part of our family, to have intimate moments with our children, to have intimate moments with our partner, to live day to day. And that’s the difference that we want to make, and that’s the big impetus behind the manuscript, the article, to start asking the question, because we can learn so much and make a big change and impact for women across the world.
Kevin Pho: Now, why do so many clinicians hesitate, or not even ask that question about intimacy?
Michael Reed: I think that’s a great thing to look at. We have to sit with it: Men built medicine, and from that we were taught only what we were taught. We can’t really mourn a door that we have never appreciated before. So all the docs out here, we love our patients. We love all our patients, men and women. We want to do the best by them. But if we don’t know, then we don’t know. And so I think the first thing is that we just have to admit that we don’t know. We don’t have that. We don’t have it. We need to figure it out and come up with a framework for physicians to use so that they have some kind of lens to guide evaluation and clinical thinking, and that’s what I think is the bigger goal. And if we can do that, that will slowly continue to make this change.
The second reason is that women are trying to make this change. We have social media out there. Women are listening to podcasts. We have urologists taking the lead, but we have OB/GYNs. We love our practices. We love what we’re doing. It is a lot for us to do, and so maybe they do need a separate division like cosmetic gynecology. But maybe we need to change it to aesthetic and functional gynecology so it’s more accepted on a broader basis. But the whole idea is that we need a group of physicians who can hear women’s experiences and provide solutions to those experiences, because we have them. We have them. We just need to get them out there so that people know that there are options.
Kevin Pho: So share a little bit about your approach to introducing questions about intimacy in the exam room. You mentioned that you had a framework. Give us some examples about what that may look like.
Michael Reed: So for me, it’s a little bit easier. My practice is designed all around women’s sexual health. I’m known to be an advocate for women’s sexual health. So when women come, they’re coming hoping that I will do exactly what I’m saying, which is to listen and to hear. Women want to know the answers. Men want to know the answers. But there’s no place to ask. So when you set up a spot and say, “Hey, you can come here and ask me whatever you want, and I’ll give you some solutions,” I don’t have any problems with people asking me.
I think it’s the same way for every physician out there. If you ask, then they know that the conversation can take place, and that’s the issue, and that’s why I wrote the article, because we have to let women know that this is real. Women’s sexual health is real. Physicians need to lead. We can’t follow anymore. We need to lead, and that means we need to come up with training. We need to think of ways to research. We need to think of clinical pathways to make things better for women and women’s sexual health. And so I’m asking. I’m pushing. I want physicians to step forward and say, “Yes, this is real. This is not a gimmick. We’re not trying to hurt women. We’re trying to improve the quality of their lives, not only by living longer, but by living well.”
Kevin Pho: Now give us examples of specific questions that you may ask, or that you recommend primary care physicians like myself ask. What are some specific examples, or verbiage and words that you would use?
Michael Reed: I think one of the simpler things is just to ask, is sex a meaningful aspect of your life? If they say no out loud, that’s OK. It’s OK to say no. Sex is not important. Intimacy is not. But if it is, they’ll say, “Yes, it is.” And then you can just say, “Well, what is it that you would like to improve upon?” And once you open that door, you’ve opened it up. And they’ll say, “Well, you know, it’s painful,” or, “I’m not experiencing orgasm,” or, “Sensitivity of the skin is not the same. I’m not as aroused as I used to be. I love my husband, I love my partner. They’re chasing me around, but I don’t feel like reciprocating.”
And so we have to ask these questions. And when we ask these questions, and we have some kind of clinical framework, and we know a selection of physicians who want to do this, then we can even have a referral basis. We can refer. But we have to ask simple questions. Do you have pain? Are there any difficulties with arousal? Is there anything regarding your intimate life that is bothering you, or that you would like to improve upon? Just simple, straightforward questions.
It was very similar to how I found my own way into this. I wish I could say I was just so intelligent and wonderful and pious that I came up with these ideas that I’m talking about. It was through my own lived experiences that I said, “Hey, we’re not doing enough.” I was 340 pounds. My wife is 19 years younger than me. We had a kid on the way. I had to fix that. So I lose weight. And while I’m losing weight, I see a TV commercial that says testosterone clinic. I look, and there are tons of them all around the neighborhood. I go to one, and they ask me that question: “Is sex meaningful for you?” I said, “Damn, no one’s ever asked that before. Yes.” And they say, “Well, what could you improve upon?” I tell them, “Well, I wouldn’t mind this, that, or the other.” And they say, “Well, let’s run some labs.” And my life changed.
And that’s when I had the aha moment, that this is going on for women, too. The infrastructure just hasn’t been completely built yet. And that’s when I said, “Well, hey, we have to go after this.” This felt great to me. I’m a woman’s advocate. I’ve been caring for women, but I haven’t been doing the best job that I can. And it’s not until we realize that, that we can make a difference. And it comes right back around to why I got on KevinMD, Kevin, because we have to make this change. We have to get the word out there. If we don’t know that that door is there, we don’t know to open it.
Kevin Pho: In your article, you shared a couple of patient stories. So give us some success scenarios where you did open up that conversation and you did make a meaningful change in that patient’s life. What would success look like?
Michael Reed: I think one success is a physician who came to see me up north. I’m in northern California. She saw me from way up in Redding, even further north. So you’re dealing with a woman who is an advocate for herself. She’s not insecure, but she’s got some issues regarding her labia majora. She went to three other physicians and another surgeon. All of them were telling her, “Hey, we don’t have anything for you. This is cosmetic.” She did decide to come see me. She had so much disappointment in her previous visits that she came in almost with an attitude, expecting the same thing from me.
And we were able to talk about a procedure called labia majoraplasty, which would remove a lot of the sebaceous cysts that were covering the entire labia majora. And we were able to do this procedure, get rid of that, and now she appreciates what she has. She sees it differently. It’s very similar to when I lost a lot of weight and got rid of my excess stomach skin. When you get rid of something that’s no longer serving you, it makes a change in how you see life. And so that’s a wonderful example.
Another one is a nurse. She is a labor and delivery nurse. She’s had very large, robust labia. She’s never ever had intimacy with the lights on. She’s tried oral sex before but didn’t like it. And she finally worked up the courage after 10 years to have the procedure done. She has the procedure done, and her life has changed. She enjoys oral sex. She loves the lights on now. The ability to just feel that experience and intimacy with her partner shot her to the moon, just from removing something that wasn’t serving her anymore.
And so I think those are a couple of powerful examples of what we do as cosmetic gynecologists: listening to women and their experiences, and not trying to find something that’s broken and fix it. Let’s listen to the experience and fix that experience so that they live better and they live longer and they live well.
Kevin Pho: How about in the primary care setting? So if I do open up the conversation about intimacy in the primary care setting, as you know, we have 15 to 20 minutes, if that, for each patient. What are some meaningful things that primary care physicians who may be listening to you here can do in the exam room?
Michael Reed: One thing they can do is show the woman her anatomy. Bring a handheld mirror. When the next patient comes to you and says, “Doc, I think I have a yeast infection,” say, “OK, let’s take a look.” Give them the handheld mirror. Show them what the labia majora is. Show them what the labia minora is. Show them where the perineum is. Let them see exactly what’s going on. If you could do that, you’d be changing tremendous lives.
When you think about it, gynecology is the only fraction of medicine where you have to believe the word of the doctor, and you get no proof. If you broke your collarbone, the doctor brings in the X-ray and says, “Look, you see your collarbone’s broken, and this is why we’re going to do this, this, and this.” Well, when it comes to GYN, we go down there and look. They have you covered. You don’t see anything. You come back over the things. You have a yeast infection, and we get up and walk away.
There’s an educational opportunity there to understand, so women can understand their anatomy. If they can understand their anatomy, and you’re talking to a 40-year-old woman, well then now she knows her anatomy, and she can explain it to her daughter. And then that daughter, when she has a daughter, can explain it to her daughter. And just from you showing her with a handheld mirror what her anatomy looks like, you have made a change that can affect generations.
So that’s one thing. Another thing would be being comfortable just with vaginal estradiol, and being OK with making a referral. Vaginal estradiol can help with vaginal dryness, recurrent UTIs, painful sex. The vagina loves estrogen. So if you have a patient who’s having recurrent yeast infections and some painful sex, say, “Listen, I want to start you on vaginal estradiol, and I’m going to refer you to X, Y, and Z,” whomever you feel comfortable with, who loves women’s sexual health, who will be an advocate for that woman. And those doctors are cosmetic gynecologists, doctors who are in ISSWSH, menopausal practitioners. All of these people are saying that women’s sexual health matters. This conversation is happening. We’re a part of it, and we’re so much a part of it that we’ve gone beyond residency and sought out education somewhere else so that we can better take care of you.
Kevin Pho: We’re talking to Michael Reed. He is a cosmetic gynecologic surgeon. Today’s KevinMD article is “The exam question OB/GYNs were never taught to ask.” Michael, let’s end with some of your take-home messages that you want to leave with the KevinMD audience.
Michael Reed: Take-home message number one: Let’s start asking the question. Let’s start saying that women’s sexual health is real. It is real. Women have concerns. They have real lived experiences. Let’s start listening to those experiences.
The second thing I would say is go ahead, get on Amazon, and if you have three exam rooms, spend 15 bucks and get three handheld mirrors for your examinations, so that you can educate your patients on their anatomy and begin to make impactful changes in their lives and for generations to come.
And the third is learn how to prescribe some vaginal estradiol. You’ll be helping so many women. You’ll be preventing recurrent UTIs. You’ll be preventing vaginal dryness. You’ll help relationships stay together. So I think those three things are a great start to making a change for women and women’s sexual health. And thank you, Kevin.
Kevin Pho: Michael, thank you so much for sharing your insight and perspective. Thanks again for coming on our show.
Michael Reed: Thank you for having me.
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