You say you experienced “pins and needles” during intercourse in your last relationship, and of course it’s difficult to feel amorous when you’re expecting pain. That’s a common description of what it feels like to have genitourinary syndrome of menopause (also called vulvovaginal atrophy) or vulvodynia. A careful pelvic exam by a skilled practitioner can diagnose the condition.

There are treatments available, starting with moisturizers and including hormones, either local or systemic, and other medication options. But a clear diagnosis is the first step.

And then the relationship component. A strong and supportive relationship is an important part of libido and desire for most women. At midlife and beyond, though, we face the “use it or lose it” phenomenon: Here’s a blog post that addresses a “maintenance plan” so that when you find the relationship that’s worth it, you’re ready for intimacy.

My car’s license plate reads “HOTFLAS.” I take it for granted, until someone rolls down his window to talk to me at a stop sign.

“Hey, I like your license plate,” he says. “You must be about 50. Wow, my wife is going through that. It’s really tough. It’s been a real challenge.”

Only a few days later, I was meeting with a colleague from a nonprofit for whom I volunteer. “Remind me what you do,” he said. It took about half a sentence from me (“I’m a doctor specializing in menopause care…”) to strike a nerve with him. “It’s like a stranger is living in my house,” he said, of his wife’s journey through menopause.

It’s Menopause Awareness Month. These men—among so many others who regularly cross my path—are aware of menopause. Now. I think it’s safe to say that the experience has taken them—and their wives—somewhat by surprise. I can’t think of another medical condition that affects so many of us—directly and indirectly—yet about which we have so little advance education.

Six thousand American women become menopausal every day (defined as not having menstruated for a year). In the U.S., the average age of menopause is 51; that’s the age the youngest of the Baby Boomers are now. We have the highest proportion of menopausal women in our population we’ve ever had—and may ever have again.

And yet, women I meet in all areas of my life—and the men who are living with them—are surprised by the range of effects from the change in estrogen in their systems. While lots of jokes (and T-shirts) circulate about hot flashes, women don’t realize that they may also have

  • Difficulty with memory and cognition
  • Increased joint pain
  • Urinary urgency and frequency, including susceptibility to bladder infections

About half of women have pain with intercourse five years after menopause. For whatever reason, many women don’t associate that symptom with menopause. Too many of us think it’s just “what happens.” Too many of our doctors don’t ask about our sex lives, so women don’t tell about their experiences. While there are a range of treatments—both over the counter and prescription—that would help, too many of us are unaware of them.

Avoiding the topic doesn’t make menopause go away. I’ll keep talking—to patients, to colleagues, to men and women on the street. I encourage you to learn everything you can, pay attention to your own health, and to join the conversation! We midlife women are indispensible resources to our families, our companies, our communities. We deserve to have this natural phase of our lives understood!

We’re always trying to give you food for thought; this time we want to encourage you to think about the relationship between food and sex. It’s pretty straightforward: Eating healthy foods leads to feeling healthy and feeling healthy both increases the likelihood that you’ll be interested in sex—not to mention that you’ll enjoy it.

There’s no easier time to eat healthfully that than harvest season, when fresh fruits and vegetables are plentiful. If you plan ahead, you can turn your quest for healthy eating into a fun activity that brings the two of you closer.

Take some time to choose a menu together, or, if your partner isn’t interested in that step, at least get buy-in for the menu that you’ve chosen. As you and your beloved stroll through the farmer’s market (or grocery store), talk about the associations you each have with fresh foods. In learning why your partner hates blueberries or loves Brussels sprouts, you might hear a childhood story that gives you new insight.

While any fresh fruit or vegetable is good for you, you may want to seek out specific ones. The folic acid in asparagus, for example, increases histamines, which are important to sex drive. Meanwhile, watermelon contains L-citrulline, an amino acid that increases blood flow to sex organs. Peaches do the same thing. And cold-water fish like salmon, anchovies, and oysters are high in omega-3, which improves everything from mood to memory. The avocado has two things going for it: its suggestive shape and the folic acid it contains.

When you have all the ingredients and have found your way home, the real fun begins: You cook together—in more ways than one.

I’m an optimist by nature.

And that’s a good thing. I saw an article this week headlined “Women are not getting treated for menopausal symptoms.” It outlines the research behind the statement, research done in Australia but believed to be indicative of the reality elsewhere, including the U.S. and the U.K.

The researchers surveyed nearly 1,500 women who were 40 to 65 years old. Some of the results:

  • Up to half experience “vasomotor symptoms,” which include hot flashes and night sweats.
  • Seventeen percent said their vasomotor symptoms were moderate to severe.
  • Eighteen percent reported moderate to severe sexual symptoms.
  • Only 11 percent of respondents said they were using any hormone therapy.
  • Less than one percent were using non-hormone therapy.

This is, sadly, in line with other research I’ve seen over the past few years. Too many of us are taken by surprise by menopause symptoms. Too many of us expect the symptoms to pass in a month or two, when in actuality they may last for years. Too many of us suffer in silence (in one study, only 14 percent of men and women over age 40 had talked to their doctors about sexual health). And too many of our doctors lack either the information or the confidence to help us navigate these years.

And there are options available. The initial “alarming” findings from the Women’s Health Initiative regarding systemic hormone therapy have been largely disproved, put into a broader context of the trade-offs between quality of life and symptom management. The North American Menopause Society points out that breast cancer risk associated with systemic hormones doesn’t usually rise until “after 5 years with estrogen-progestogen therapy or after 7 years with estrogen alone”—which is likely long enough to weather the worst of menopause symptoms.

Localized hormones are an option for some symptoms; because they’re applied directly in the vagina, very little is circulated throughout the body. That limits or eliminates the risk of side effects, while still offering benefits in maintaining or restoring vaginal tissues.

New nonhormonal options for menopausal symptoms are also available, approved by the FDA. Osphena is a “selective estrogen receptor modulator” (SERM) that targets the vagina and uterine lining. Duavee is another medication in the SERM category that can be effective for hot flashes, with potential benefits for bone density. Brisdelle is an antidepressant that’s been prepared at a dosage that can help with hot flashes while minimizing its occasional side effects of weight gain and loss of libido.

Those are all prescription options, and there are plenty of steps women can take on their own, as well. That’s really our entire message, but if you’re looking for a place to start, these are the products women find most immediately helpful:

  • Lubricants make uncomfortable sex immediately more comfortable.
  • Moisturizers have longer-lasting effects, and can be used with lubricants to counter vaginal dryness.
  • Vibrators, as I tell women in my practice, are the reading glasses for diminished genital sensation.
  • And Kegel exercise tools help women keep their pelvic floors in shape, which is good not only for sexual response but for managing incontinence.

See how many things we can do? We don’t need to “grin and bear it,” as researcher Dr. Susan R. Davis, from the Monash University in Melbourne, fears we think. Step one is to believe—share some of my optimism!—that something can be done.

And then learn what you can, talk to your health care provider about your history, symptoms, preferences, and risks. Feel free to experiment until you find some options that make you smile.

The FDA’s announcement yesterday that they’ve approved flibanserin is huge for women. This is the first medication approved for treatment of hypoactive sexual desire disorder (HSDD), also called female sexual dysfunction (FSD) and, more recently, female sexual interest/arousal disorder (FSIAD—a new abbreviation!).

The multiple names for the condition we’re treating tell a story all by themselves. It’s been a long road to get sexual arousal issues for women the same attention as has been paid to erectile dysfunction in men, perhaps because the symptoms are less visible. The media coverage of the process, I’m hopeful, has had some educational effect, endorsing FSIAD as a real medical condition with real potential for treatments. I have new reason to be optimistic that this decision will lead to further developments in the field—because it’s been proven that it is possible to get a medical treatment in this arena through the FDA approval process.

This approval is great news for women who suffer from this specific medical diagnosis, for whom I, as a menopause care specialist, have had nothing to offer. It’s great news for their partners, who, along with the women, have some hope and optimism that the desire and passion they once shared may be restored to their relationships. I’ve heard from women in my practice about the double-whammy of their loss of desire: Not only do they miss their sexual selves, they regret the unintentional messages they’ve sent their partners.

I’m hopeful that hearing about this development will encourage more women to be frank with their health care providers. At least half of women will have sexual difficulty at some point, but far fewer of them will bring it up to their doctors. If they know there’s a possible treatment, perhaps women will have more motivation to ask. I haven’t seen a study, but I’d be willing to bet that more men asked doctors about erectile dysfunction when they’d heard Viagra was available.

Together with my patients facing the FSIAD diagnosis, I can have a conversation about the potential benefits and side effects of this medication. We can make a plan of action. The women I serve aren’t expecting miracles; any possibility of even a modest improvement will be life-changing for them.

As a doctor, I’ll now have something to say after “no, it’s not all in your head” and “I’m sorry.” I can’t wait.

Even though I’m a medical doctor, I’m not accustomed to watching the Food and Drug Administration’s actions as closely as I have the past few months. If you’ve followed this blog, you know that last October, I traveled to Washington DC for a public hearing and then a workshop of women’s health experts. The FDA sponsored the events to hear about women’s sexual health and to examine how they might respond.

And then in June, an advisory committee to the FDA recommended the approval of flibanserin, a medical treatment to address hypoactive sexual desire disorder (HSDD). The FDA is poised to announce its decision next week.

It’s been a long road. I first wrote about flibanserin back in 2010, when the company that had developed fibanserin shelved it, saying that it didn’t have sufficient “potential to make it to market.” There’s been controversy about the HSDD diagnosis, although it was first medically characterized in 1977 in the Journal of Sex and Marital Therapy and is listed in the International Classification of Diseases.

More important to me than those scientific listings are specific women I’ve seen in my practice. They’ve had satisfying sex lives. They love their partners. They want to want intimacy. They don’t have psychological problems, relationship issues, social hang-ups, or a medical problem—beyond HSDD. Brain scans show different activity and structure in women with HSDD, proving the biological component.

As their doctor, I want to offer them options to reclaim the life they want, which includes intimacy. It’s up to each woman to decide which of the options she’s like to try, and then to determine whether each option is working for her.

Beyond the approval of this one pharmaceutical product, the FDA’s action is, I hope, a signal for a bright future. When I was there in October, I heard that the agency “recognizes that this [female sexual dysfunction, or FSD] is a condition that can greatly impact the quality of life,” and that “the FDA is committed to supporting the development of drug therapies for FSD.”

As a physician, I’m committed to the least invasive, simplest solution for each woman. But when that simplest solution doesn’t work, I’m deeply grateful for well-tested, thoroughly researched pharmaceutical options that help women restore the fullness of their lives.

Almost as soon as we posted the piece on how to bring up difficult topics, a reader asked “But how do I get my husband to listen?”

It’s an excellent question, and we put it to our friend Ann McKnight, a social worker and psychotherapist. Her answer might surprise you. If you feel like you’re not being heard, you might want to look at yourself first. “You have to ask yourself, ‘Is this really about me getting my way?’ If it is, you’re virtually guaranteed the conversation won’t go anywhere,” she says. “Most of the time, we engender defensiveness in the other person because of the way we say things.”

That defensiveness shuts down the opportunity for real communication, and the conversation ends before you’ve gotten to the issue, even if you’re still talking. That defensiveness is rooted in fear—fear of being judged, criticized, blamed, shamed, cut off. Just as fear interferes with our willingness to bring up difficult issues, it interferes with the other person’s willingness and even ability to really listen. Fear is the ultimate intimacy blocker.

Your genuine desire to understand what’s going on with the other person is critical to that person’s listening skills. Arriving and hanging onto that desire while you’re talking about a touchy subject isn’t easy, but it is possible.

Here are three things Ann says you can do to improve the chances that your beloved will be able to hear what you’re saying.

Be curious. That thing your loved one is doing? He or she is probably doing it for a good reason. “The conversation needs to be ‘There are clearly some things about this behavior that are working for you, so let’s talk about those.’ After you connect about those reasons, then you have a more interested audience. Repeat the reasons back in a nonjudgmental way, and then ask if the person is willing to hear what’s not working for you. If you can get to that place, then you have an opportunity for an open dialogue.”

Make sure you’re staying connected. “That means the other person is experiencing that I am in a place that’s open to hearing them. It doesn’t mean I have to agree. Only that I care if they are feeling judged and I care about their thoughts,” says Ann.

If the other person hears judgment or criticism or blame—even if you don’t think you’re conveying any of that—the connection will be lost. Increase your chances of maintaining the connection by, at the outset of the conversation, saying something like: “I have something to share with you and I’m not coming from a place of criticism [or blame or whatever], so if you could raise your hand when you’re feeling that, then I can reassure you in the moment or I can say, ‘You’re right. I am being critical.’”

Let go of the outcome. Finally, go into the conversation with absolutely no attachment to the outcome, and keep an open mind the entire time. Once you hear what it is about the other person’s behavior that is working for them, says Ann, “your attachment to ‘You need to stop this right now’ changes and you think, ‘Maybe, given what works for other person, there’s a different way to solve this.’”

Throughout the conversation, keep demonstrating to the other person that the conversation is not just about you getting your way. “You keep throwing them a lifeline by asking ‘What is it like for you to hear what I just said?’ That shows the person that you actually care about their response to what you’re saying.”

Throw that lifeline enough times and your partner just might start throwing it back to you. That’s not just a way to resolve a difficult issue—it’s also the way to increased intimacy.


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