Viagra for Women?

You may have seen the headlines about a new medication hitting the market. Flibanserin, trade named Addyi, has been hailed as ‘female Viagra’, the ‘little blue pill’ for women, and a game-changer in the treatment of low libido (decreased sexual desire) in women. But many of these ‘news’ stories have more in common with paperback bodice-ripper novels and than they do with real, medical science. So let’s bust some myths and discuss what these pills, both Viagra and Addyi really are and what they can and can’t do.

Viagra (medical name: sildenafil) works for men with erectile dysfunction (ED) by increasing blood flow to the penis. This allows a man to get and keep an erection which is hard enough for sexual intercourse. Viagra works by inhibiting a specific enzyme, allowing for greater concentrations of a chemical called nitric oxide in penile tissue. Elevated levels of nitric oxide result in relaxation of the smooth muscle in the walls of blood vessles. So, by causing relaxation of these blood vessel walls, the vessels enlarge and can hold more blood, engorging and enlarging the erectile tissue of the penis.  It all sounds pretty sexy, doesn’t it?

That’s right. The sole medical purpose of Viagra is to allow men to get more satisfactory erection in response to stimulation of the penis. Viagra does not have any direct effect on libido or sex drive. That being said, getting a harder, longer lasting erection and a more satisfying sex life can have an indirect effect on libido (so can a good Ryan Gosling flick, if you ask me. But you didn’t.).

Addyi (medical name: flibanserin) on the other hand, does have a direct effect on libido. As we all know, libido is centered in the brain (and, according to conventional wisdom, women only have one brain whereas men sometimes have two. But we won’t go there).

Flibanserin is a serotonin agonist, meaning that it binds to (but does not activate or ‘turn on’) receptors for serotonin, a neurotransmitter (chemical signal) in the brain. It also increases circulating levels of 2 other neurotransmitters, norepinephrine and dopamine.

By altering responses to these chemical signals in the brain, it is said to directly affect sexual desire and libido. In actuality (ie, in clinical trials), the medication increased the number of satisfying sexual events per month by about one half to one over placebo from a starting point of about two to three.  That’s not bad. But it’s certainly not Love Potion #9.

So, how does it work? Well, the mechanism of action of Addyi is very similar to that which is seen in some types of anti-depressants. In fact, Addyi was originally developed as an antidepressant before being re-purposed and re-branded as a libido-boosting treatment for women with hypoactive sexual desire disorder. (I swear, that’s what it’s called. Thanks, Science!).  So, whereas Viagra acts on erectile tissue and not on the brain, Addyi acts on the brain and not on female erectile tissue (I swear, that’s what it’s called. Thanks, Science!).

Both Viagra and Addyi can have significant side-effects and neither should be used without a doctor’s prescription and supervision.  And certainly, neither should be purchased from an unregulated or online supplier.  That’s a recipe for disaster (or for Tiramisu, which also may have an effect on female sexual response, especially when eaten while watching Ryan Gosling).

So, now that you know a little more biochemistry, aren’t you kinda a little turned on?  I sure am.  Time to watch ‘The Notebook’ and eat some espresso-soaked ladyfinger cookies with mascarpone.

October 2, 2015 at 5:49 pm Leave a comment

Hot off the presses: Menopause & Flashes

Sometimes I write original content for this blog.

Sometimes, I’m quoted in the NY Daily News.

Follow the link above to Erica Pearson‘s article about menopausal hot flashes or read the text of her excellent article copied below:

Exported.; nikhil;

Menopausal hot flashes can last for more than 7 years: study

Previously, women were thought to have symptoms for only a year or two. New study shows the sweats last longer — and are worse for blacks and Hispanics.

The hot flashes and night sweats that make menopause miserable for many women can last for more than seven years — much longer than previously believed, new research shows.

For the more than half of U.S. women who have frequent symptoms as the life change begins, the median length of time that menopause lasts is 7.4 years, according to a study by Wake Forest Baptist Medical Center, published Monday in JAMA Internal Medicine.
That’s no surprise to Sandra Bouknight, 58, a retired maintenance worker from Brooklyn, who said she’s spent more than eight years dealing with menopause symptoms.

“It’s a crisis to go through. Hot flashes, mood swings. You start sweating like crazy, and then sometimes you get so moody you want to fight,” Bouknight said.
“For me it started when I was still in my 40s,” she said.

The study of nearly 1,500 women suffering frequent hot flashes found that symptoms are longer-lasting among blacks and Hispanics.

Some women were still waking up covered in sweat 14 years after the first symptoms began, the study found. The length varies depending on how early in a woman’s life the symptoms first begin, researchers found. On average, menopause begins at age 51.


As many as 80% of U.S. women experience symptoms during menopause, the study’s authors said.

“Hot flashes are very, very common,” said Dr. Linda Nicoll, an obstetrician/gynecologist at NYU Langone Medical Center.

“People complain of a sensation of warmth travelling up the body,” she said.

Nicoll said she often recommends the lowest form of intervention first, such as dressing in layers and avoiding triggers like spicy foods or caffeine.


However, some women find the symptoms interfere with their daily life.

Low-dose antidepressants called selective serotonin reuptake inhibitors, or SSRIs, are one option to treat menopausal symptoms, Nicoll explained.

Other treatments include hormone replacement therapy — which, in some forms, is linked to increased breast cancer risk — or herbal supplements like soy or black cohosh.

– With News Wire Services


February 20, 2015 at 6:28 pm 1 comment

The Hidden Costs of Egg Freezing


Unless you’ve been living under a rock lately, you’ve been hearing a lot about egg freezing (medical name: oocyte cryopreservation).  First of all, let me say it: I’m a BIG fan of egg freezing.   100% behind this.  Why?  Because it gives women options.

Egg freezing allows childbearing to be postponed in the interest of pursuing higher education, establishing a career, achieving financial stability, finding the right partner, and doing all of the things people do in their 20’s and 30’s.

But this blog post is dedicated to the hidden costs.  I’m talking finances, people.  This post isn’t about the pros and cons of ‘delayed childbearing’ (a phrase which sounds pretty judgmental already).  It’s about the logistics.  I already have a Jewish mother to tell me about the other stuff.  I’m sure you too have somebody doling out the same well-meaning advice (but maybe without the amazing brisket).

So, back to cold hard cash. If you read online about fertility preservation, you’ll see that the cost varies.  Estimates for the egg freezing hover around the $10,000 mark per cycle.  But, what does that mean?  Why would a woman undergo more than one egg freezing cycle?

When a woman goes through an egg freezing procedure, the number of eggs produced will vary.  It will vary depending on a number of factors including age.  Younger women tend to produce more eggs per cycle.  There are other factors too, but age is a biggie.

Some women, including women under 35, will not produce the desired number of eggs with one cycle alone.  I say ‘the desired number’ because that varies too. Some doctors recommend freezing approximately 10 eggs.  Some say 20.  There is no hard-and-fast rule.  A woman may then choose to undergo one or more additional cycles in order to achieve that desired number of eggs.

Also, some of those eggs will not be of sufficient quality to survive the freezing process.  Among those that survive, some will bear genetic material which is abnormal.  That’s also a concern that increases with age.  So older women may choose to freeze more eggs because they are concerned that a larger percentage of the frozen eggs will not produce a healthy baby.

So, the older a woman is, the more likely she may undergo more than one cycle.  This hidden cost can significantly increase the expense of egg freezing.

Another potential hidden cost is storage.  It costs an average of $500 per year to store frozen eggs.  That’s just an estimate– the actual number will vary by location, clinic, and other factors.

Bear in mind, the longer the eggs are stored, the more you’re paying.  So if you’re not using the eggs for 10 years, that could be another $5,000 you’re shelling out (pun intended).

So ok.  Now you’re ready to use your eggs.  Mazal tov (from my mother).

The eggs will neeed to be thawed and fertilized, and the resulting embryo(s) will be implanted in your womb or the womb of your surrogate.  This is IVF (in-vitro fertilization).  You’ve probably heard of IVF.  Usually, IVF involves embryos that are fresh or frozen.  The difference here is that the embryo is created fresh from your frozen egg.  You got that?

The thing to know is that IVF costs money.  The money pays for thawing and fertilizing the egg (to create the embryo), using medicines to prepare the uterus for pregnancy, and implanting the embryo.  This can cost several thousand dollars.  AGAIN.

So, now the embryo is implanted in the uterus and is growing nicely.  Eventually, it will become a fetus.  And then, with luck, a healthy baby.  And guess what babies cost– MORE MONEY.  You thought egg freezing and IVF was expensive?  Ha!  Try clothing, feeding and educating a kid.

But the good news is that my mother tells me it’s totally worth it.  Grandchildren, after all, are priceless.





February 20, 2015 at 5:39 pm 2 comments

HPV Vaccination – Protection for you and your daughters

What if there was a vaccine that offered you protection against the second most common and fifth deadliest cancer in the world.  

Would you take the vaccine? 

Would you give it to your daughter? 

 These aren’t rhetorical questions.  Because that vaccine exists.  Its  was approved by the Food and Drug Administration (FDA) in 2006 and is intended to prevent cervical cancer. 

The human papilloma virus (HPV) can be linked to the development of almost all cases of cervical cancer.  Although there are over 60 different types of the HPV virus, approximately 70% of all cases of cervical cancer can be linked to only two specific, high-risk types.  These HPV types are known as HPV type 16 and 18.    So, vaccines preventing high-risk HPV can significantly reduce the risk of cervical cancer in women receiving the vaccine.


The first vaccine against HPV, Gardasil, was developed to target types 16 and 18.  It also targets HPV types 6 and 11, which are linked to the development of genital warts (but not cervical cancer).  It was approved in 2006 for girls and women ages 9 to 26.   Gardasil is also approved for use in boys and young men aged 9 to 26, but that’s beyond the scope of this post.

Another HPV vaccine was approved in 209. This vaccine, Cervarix, is designed to prevent infection from HPV types 16 and 18, and offers some protection against HPV types 45 and 31.  Cervarix also contains an ingredient believed to boost immune system response to the vaccine.  It is given to girls and women ages 10-25.

Both vaccines are most effective at preventing HPV disease when given before a young woman becomes sexually active.  That’s because vaccines are designed to prevent infection, but don’t treat infection once it has occurred.  Both vaccines are given as a series of 3 injections over a course of 6 months.

Some people ask whether the HPV vaccine can be given to women who are already sexually active.  Yes!  It can even be given to women who have already been diagnosed with an HPV-related condition (such as an abnormal pap smear or genital warts).  While an individual who has been diagnosed with an HPV-related condition has probably been exposed to at least one strain of the HPV virus, that doesn’t mean she’s been exposed to all of them.  So the vaccine may protect against one or more strains of the HPV virus to which she is currently vulnerable.

Studies have shown that both Gardasil and Cervarix prevent nearly 100 percent of the precancerous cervical cell changes caused by the types of HPV targeted by the vaccine for up to 4 years after vaccination among women who were not infected at the time of vaccination

That’s some pretty dramatic stuff.  And If I’m gonna make a statement like that, I’m gonna cite a source (“Human Papillomavirus (HPV) Vaccines”. National Cancer Institute (NCI). 2009-10-22. Retrieved 2009-11-11.). 

Most health insurance companies cover one or both HPV vaccines for women and girls within the recommended age range (9-26 for Gardasil, 10-25 for Cervarix).  Some health care providers will administer the vaccine to women over the age of 26, but that can be discussed with the individual provider and won’t be discussed here.  Women without insurance, or those whose insurance doesn’t cover the vaccine, can pay for it out of pocket, but the cost is often prohibitive.  A doctor’s office or clinic can give an estimate of cost.

The Vaccine Information Statement for Gardasil gives a tremendous amount of useful information.

So does this HPV Vaccine FAQ sheet from the American College of Obstetrics and Gynecology.

For more information and individual advice, speak to your healthcare provider.

May 24, 2013 at 7:55 pm 1 comment

HPV 411: The scoop on Human Papillomavirus

HPV (human papillomavirus) is a big topic nowadays. Patients are asking about it because it has been addressed as a topic in popular media (The HBO series ‘Girls’), because of commercials for the HPV vaccines (Gardasil and Cervarix), and because the have heard about it in the context of an abnormal Pap smears.  There’s a lot of misinformation out there (particularly in the media) and I’d like to combat it with some facts.

First, let’s review what the virus is and what it does. HPV is not just one virus. It’s a family of viruses, of which over 30 different types (identified by numbers such as ‘Type 16’) infect the anogenital area and can be transmitted by sexual activity. 

**Barrier contraception (such as condoms or dental dams) can prevent most HPV transmission between partners.** 

Some types of HPV cause genital warts. These types are typically described as ‘low-risk’ for subsequent development of precancerous or cancerous lesions. Genital warts are visible on the skin and mucous membranes. They are often noticed by patients on self-examination. They can also be diagnosed by a doctor at the time of an annual visit during a visual inspection of the genital area.

Some HPV types are described as ‘high-risk’ for the development of precancerous or cancerous lesions. That’s these types of HPV infection are the cause of nearly all cases of cervical cancer and may be linked to rarer cancers of the vulva (female external genitalia), vagina, anus, penis, and oral region. Most infections with even these ‘high-risk’ types resolve spontaneously (i.e. without treatment) and do not cause disease.

HPV screening in women is done indirectly through the use of Pap smears or Pap tests. A Pap smear is a microscopic evaluation of cells obtained by swabbing the cervix. These cells are examined for the types of cellular changes typical of HPV infection. A Pap smear is often performed by a doctor or other health care provider at the time of a woman’s routine annual visit.  An abnormal Pap test requires further evaluation, usually with colposcopy (see below).

HPV testing can be performed directly by a laboratory. A sampling of cervical cells (obtained by a healthcare provider at the time of a Pap smear) is sent to a lab to detect the presence of DNA from the HPV virus. This test is usually reserved for women over 30 or those who have already had an abnormal pap smear. HPV testing is not routinely performed on men, nor is it routinely performed in the anal or oral region. That’s because cancers of these other organs are rare in comparison to cervical cancer.

Most HPV infections in young women are self-limited (i.e. they resolve on their own and without treatment) and have no long-term health consequences.  Up to seventy percent of HPV infections resolve in 1 year and ninety percent may resolve in 2 years.  However, when the infection persists — in 5% to 10% of infected women — there is a significant risk of developing precancerous lesions of the cervix.  Over 10-15 years, these lesions can progress to invasive cervical cancer.  The long interval between precancerous lesions and their development into cancer allows ample opportunity for detection and treatment of the pre-cancerous lesion. Progression to invasive cancer can be almost always prevented when regular screening detects precancerous lesions and treatment is provided in a timely fasion. 

A colposcopy (from the Greek kolpos “hollow, womb, vagina” + skopos “look at”) is done to evaluate the cervix after an abnormal Pap result.  The colposcope itself is just a microscope with a light allowing a doctor to examine an illuminated, magnified view of the cervix, vagina and vulva.  Many premalignant and malignant lesions have specific characteristics which make them look ‘suspicious’ when examined in this fashion.  These areas can then be targeted for biopsy (taking a piece of tissue to be evaluated by a Pathologist). The main goal of colposcopy is to prevent cervical cancer by detecting precancerous lesions early so that they can be treated before they become malignant. 

Treatment of precancerous or premalignant lesiosn usually involves minor surgical procedures (a LEEP or a cone biopsy) in which uses a cauterizing loop or other small cutting instrument to remove the affected part of the cervix.   Patients are usually advised to avoid sexual intercourse for at least 6 weeks to allow complete healing.  Cryotherapy (freezing the affected portion of the cervix with liquid nitrogen) is also used in some areas where the aforementioned procedures are not feasible (i.e. in the developing world).  Cryotherapy is not usually used for premalignant lesions because it is less likely to remove the entire lesion and  because there is no way to reliably identify the extent of tissue destroyed.  Therefore, it is considered a less effective therapy and is used only for lesions which are not precancerous or in situations in which a LEEP, LETZ or cone biopsy cannot safely be performed.

There is some increased risk of reduction or loss of fertility and an increased risk of certain pregnancy complications (including preterm birth) with some of these procedures, especially if they need to be repeated several times.  A doctor who performs these types of procedures can go into greater detail about the risks of a specific procedure he or she recommends.

**In summary: HPV can cause cervical cancer.  The best defense against cervical cancer is to get reguar screening with Pap smears and HPV tests as recommended by your healthcare provider.  An abnormal screening test deserves prompt follow-up and may require colposcopy.  Medical procedures (LEEP, cone biopsy) which are performed on individuals with HPV infection at the time they are diagnosed with precancerous lesions are effecive at preventing cervical cancer.   These procedures may carry a risk of pregnancy-related complications and should be discussed with your healthcare provdier.  Condom use and HPV vaccination may prevent some HPV infections.**

I’ll be blogging about HPV vaccination next.

July 23, 2012 at 8:02 pm 6 comments

Learn more about Minimally Invasive and Robotic Surgery

I’d like to invite you to my website

I’m a strong believer in laparoscopic and robotic surgery for a single, simple reason. It’s better for the patient. Minimally invasive surgery, a catch-all term which includes laparoscopy, hysteroscopy, and robot-assisted surgery, has proven benefits.

The benefits of minimally invasive surgery, compared to conventional “open” surgery include:

• less post-operative pain
• reduced need for pain medication
• faster return of normal appetite and bowel function
• smaller incisions
• less scarring
• faster recovery and return to work

Robotic surgery in particular has advantages which allow the surgeon to perform more complex procedures via a laparoscopic approach than might otherwise be possible. The robotic system gives the surgeon the benefits of:

• greater magnification with the laparoscopic camera
• 3 dimensional (3D) vision
• greater range of motion for laparoscopic instruments
• increased comfort, which may reduce a surgeon’s fatigue during long procedures
• reduction of biologic hand tremor

The robot doesn’t bear much resemblance to what we’ve come to expect from science fiction. It doesn’t have artificial intelligence and it cannot operate independently. In fact, the robot is just another instrument. It is controlled by the surgeon who sits at a console next to the patient.

The Da Vinci Robotic Surgical System

The robot has arms whose attachments are miniature versions of conventional surgical instruments (i.e. scissors, clamps, needle and suture-holders). These tiny instruments mimic the surgeon’s movements at the console (but on a much smaller scale). This allows the surgeon to perform surgical procedures with extraordinary precision.

Laparoscopy revolutionized surgery by making many major surgeries into outpatient procedures. Robotic surgery is revolutionizing laparoscopy by broadening the range of surgeries which can be performed with a minimally-invasive approach.

Take charge of your health by learning more about minimally invasive and robotic surgery. An educated patient is an empowered patient!

February 25, 2012 at 12:51 am 4 comments

2011 in review

The stats helper monkeys prepared a 2011 annual report for this blog.

Here’s an excerpt:

The concert hall at the Syndey Opera House holds 2,700 people. This blog was viewed about 19,000 times in 2011. If it were a concert at Sydney Opera House, it would take about 7 sold-out performances for that many people to see it.

Click here to see the complete report.

January 4, 2012 at 5:50 pm Leave a comment

Older Posts

Linda M. Nicoll, MD

Welcome to my blog! Here you will find information about minimally invasive gynecologic surgery as well as some more general information about common gynecologic disorders such as endometriosis, ovarian cysts, fibroids, infertility, and pelvic pain.

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