Sex, Menopause & Cultural Differences with Dr. Sameena Rahman

Menopause is defined as the time when you haven’t had your period for a year. But across people, that’s kind of the only universal truth. We were so lucky to be able to welcome Dr. Sameena Rahman on a recent webinar with our community manager Rachel Hughes to talk about sexual health, culture, and religion. 

We edited the interview for clarity and length, but we highly recommend you watch the whole thing on our YouTube!  

Rachel Hughes:

Here we go. Welcome everyone. I am Rachel, Community Manager here at Alloy Women's Health. We are a telehealth company bringing science-backed, evidence-based hormonal solutions for menopause directly to your door. Today we’re joined by Dr. Sameena Rahman. Dr. Rahman is a board-certified OB-GYN, with a practice tailored to meet the needs of women for gynecologic and cosmetic services, and she's actively involved with cutting-edge approaches to sexual pain and sexual dysfunction. She's also an active member of the International Pelvic Pain Society and specializes in a multidisciplinary approach to chronic pelvic pain. She is a menopause and sex medicine specialist, and she has an academic affiliation with Northwestern University’s Feinberg School of Medicine. Her private practice is in downtown Chicago. Welcome again to the Alloy community.

Dr. Sameena Rahman:

Yay! I love Alloy. I love all the docs at Alloy. I love you.

Rachel Hughes:

Today we’re talking about sexual health and the challenges many women face physically and hormonally, and also in terms of their cultures and religions. So, let’s kick this off. 

Dr. Sameena Rahman:

Absolutely. Well, thank you for having me. I'm very excited to be on this webinar.

A little about me: I’m South Asian, I’m Pakistani, and I’m Muslim. I was born in America. My parents are immigrants. So, obviously that’s really loaded. If you’re a first generation immigrant family coming into America, there’s a desire to hold onto some cultural aspects of your life. And if you think about being Muslim traditionally, it’s socially and sexually conservative, as many religions are. On top of that, I grew up in the south, in North Carolina. 

How we look at sex is very much consistent with how we’re brought up. And then there’s biology, and there’s midlife. You end up with less estrogen, and less testosterone. So when it comes to sexual health, we need to take a biopsychosocial approach. 

Rachel Hughes:

I so appreciate that. So, tell us some of the primary reasons patients come to see you.

Dr. Sameena Rahman:

Oh, in my office, really they're vast. I focus on midlife women. So there's issues of just generalized symptoms around menopause and hormone therapy, and then more specifically, there are issues around sexual pain and pelvic floor dysfunction, there’s vaginismus, issues with the vulva, inflammatory skin conditions, vaginal infections, endometriosis, fibroids…. 

Rachel Hughes:

I wanted to highlight a few of these conditions. What is vaginismus? And, is it related only to hormones, or can trauma play a role? 

Dr. Sameena Rahman:

When we learned about sexual dysfunction in residency, vaginismus was all they told us about. It’s a form of pelvic floor dysfunction, but specifically, it’s an involuntary contraction of your pelvic floor. I like to call it almost an anxiety reaction to the pelvic floor, and it can be sort of secondary to a lot of things.

Most of my patients that have untreated genitourinary syndrome of menopause (GSM) end up with vaginismus because they start trying to have sex and it’s uncomfortable. When that happens and you’re experiencing a lot of pain, you involuntarily contract. And that can also be related to cultural and religious baggage that we sometimes carry around sexual identity. And then you also have patients who maybe have experienced sexual trauma, and then all of a sudden your anticipation is pain and then you have an involuntary reaction. 

Rachel Hughes:

Where do you begin to treat that? Is that a pelvic floor PT kind of remedy?

Dr. Sameena Rahman:

Pelvic floor therapy is a mainstay when it comes to treating vaginismus. Cognitive behavioral therapy can also help. And, I’ve also used Botox for vaginismus, and then there’s dilator therapy. And if there’s hormones involved, we treat that. It’s really a multidisciplinary approach. 

Rachel Hughes:

Thank you. I also would love to talk about Vulvar Lichen Sclerosus and why it’s often missed in women of color.

Dr. Sameena Rahman:

Vulvar Lichen Sclerosus is an inflammatory skin condition of the vulva, and it's usually a lifelong skin condition. We think there's an autoimmune component to it–there’s possibly a protein in your skin that your body views as foreign, and so then you have these inflammatory markers that come and start to act upon it, and the architecture of the vulva changes, and you get a thickening of the skin. You can get changes to pigmentation (either hyperpigmentation or vitiligo, when your skin loses color, or both) and you can also have a labia regression, where the labia become smaller, or can disappear totally. With the clitoris, if your skin is becoming thicker, it can get hidden under the hood and you may not be able to see it at all. 

There’s not enough research done on women’s sexual health in general, and with women of color, that is compounded. And we have to push for more research. We often misdiagnose patients and then they don’t get the appropriate treatment. And there’s a small percentage of people in whom vulvar lichen sclerosus turns into vulvar cancer. So it’s important to do biopsies.

We have to really push for more research when it comes to all of these topics, but specifically, we need to look at some of the disenfranchised groups in the United States and see if we can really get to the bottom of why they experienced sometimes worse symptoms. They're neglected the most and they get the least amount of therapies offered to them. 

Rachel Hughes:

Thank you so much for that, Dr. Rahman.

Can you speak a bit to superficial dyspareunia? 

Dr. Sameena Rahman:

Yes. That just means pain with sex on entry. So it’s a descriptive term that describes what’s happening, but not the reason it’s happening. And there can be a variety of reasons. At the opening of your vagina, which we sometimes call the vestibule, there can be pain. It can be hormonal and come from GSM, or pelvic floor dysfunction, or inflammation.

Rachel Hughes:

Does vaginal estrogen help with any of those conditions?

Dr. Sameena Rahman:

Absolutely. We know that estrogen receptors are in the vagina, they're in the vestibule. So that can help. There are also testosterone receptors in the vagina so for some patients vaginal estrogen is not enough, and there are additional options available as well.

Rachel Hughes:

Thank you. I want to give you an opportunity to speak about this paper that you worked on. It was published in Sexual Medicine Reviews and it looks into the sexual dysfunction of Muslim women around the world. I’m curious what your findings were. 

Dr. Sameena Rahman:

I did a paper in 2018 just on some of the sexual dysfunctions that Muslim women experience. I looked at different countries that are predominantly Muslim to see what their research is. And there and in the United States, we don’t have a lot of it. We looked at things like unconsummated marriages, genital cutting, issues around chastity and the hymen and hymenoplasty and stuff like that. So I talked about all that in that one paper. And then we wanted to look at factors that are really contributing to sexual pain in Muslim women. And to sum it up, we need more education. 

Some clinicians are not comfortable speaking about sexual dysfunction. So there's that. There's the patient barrier to understanding their anatomy. There's family involvement in a lot of these cultures. And there’s shame around sexual dysfunction, menstruation, and all that stuff is so prevalent in some of the cultures that it just transmits into generations. And there's still this lack of communication and lack of education that continues and it kind of snowballs into all of the problems that we're experiencing. And traditionally, Islam was a very sex positive religion. And so that's why I'm always shouting about this because I think we have to educate everybody. 

Rachel Hughes:

Thank you for that. Okay, Dr. Rahman, I want to get to two questions from our audience. First:

Hello, I’m 66 and have been in menopause for probably 10 years. I’ve never had hormonal labs done. I will be getting them checked and possibly getting on a hormone regimen. Can it really help with dryness, libido, weight loss, mood, sleep? I just want to feel better or happier. I want to go through life feeling good. 

Dr. Sameena Rahman:

Oh, yes, absolutely. And you deserve to go through life feeling good. Checking hormones at this point is probably going to show what we expect: low estrogen, low testosterone, high FSH. 

Systemic hormones can help with vasomotor symptoms, heart health, bone health, and energy. And when it comes to GSM, vaginal estrogen. It can be lifesaving. There’s also testosterone, but it’s tricky because testosterone is not really approved for us, so we have to work with the male version of it and titrate it to a level that will get us to premenopausal levels.

Rachel Hughes:

Next question:

Are any of the inserted battery or electric devices for pelvic floor exercises helpful?

Dr. Sameena Rahman:

I think that many of them are. There's wands and other things that you can use to help to diminish any of the trigger points you might feel in the pelvic floor, so some of that stuff at home is helpful. Sometimes even trying to strengthen your muscles by contracting around them, that's helpful. I think that if you can't see a pelvic floor therapist regularly, getting an initial evaluation and seeing their suggestions is worthwhile. Pelvic floor therapists are miracle workers in so many ways to really help in that area.

Rachel Hughes:

Thank you, this is so fascinating. Next:

How can you tell the difference between GSM and Vulvar Lichen Sclerosus?

Dr. Sameena Rahman:

That’s a good one. Honestly, sometimes they coexist. In a lot of my postmenopausal patients, if they have lichen sclerosus, vaginal estrogen is key because without it, symptoms can be worse. The symptoms can be similar, so telling the difference can require an examination, and possibly a biopsy. 

Rachel Hughes:

I want to ask my last question. I’m thinking about women, who, for cultural reasons, religious reasons, or trauma, remain hesitant, even in midlife, to walk into their gynecologist’s office and say, “I think something is going on with me and I need help.” And I'm wondering what you might offer to those women to encourage them to take steps toward their own healing. And then I’m thinking about the practitioners who may feel uneducated, how they might begin to treat their patients better. 

Dr. Sameena Rahman:

Right. No, this is a big problem. I like to speak whenever I speak at conferences and stuff, and I always include something about implicit bias. Our system is broken. 

So first we have to make sure patients understand, this is not your problem. And when it comes to clinicians, I’d like to say we should really keep our minds open. Let a patient tell their story. Don’t interrupt them and say, “Oh, because you're black or brown or this or that, this is why.” No, you let them tell their story and you listen to them and check your bias at the door if you can. I think that you have to really say, “You know what? This is okay. This has happened to almost every patient that goes through this. You are not alone. You are not broken. This is okay, and you need to just tell us about what's happening.”

Rachel Hughes:

What a way to end. You are an advocate. You are an educator. You are a physician, a clinician. You are constantly highlighting and banging the drum on behalf of, and for women who've been so marginalized, not involved in the research, as you said, not treated well, and I am so grateful and thankful. Thank you.

Rachel Hughes:

You as well, Rachel. I'm so thankful for your advocacy and all the work that you're doing as well.

Thanks again to Dr. Sameena Rahman for joining us. Watch the entire interview on our YouTube, follow us everywhere @myalloy and subscribe to our emails to learn about upcoming events!