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Connect the dots for me here:

  • Research consistently ranks good sex as an important component of quality of life.
  • Back pain is a serious deal-breaker to good sex because when your back hurts, sex does too.
  • About 31 million people suffer from low-back pain in the US, according to the American Chiropractic Association.
  • From 34 to 84 percent of those people have sex less frequently, depending on what study you read.

Ergo, if you suffer from back pain—and a whole lot of people do—you’re probably having sex less and enjoying it less, as well.

That’s a lot of lost quality of life.

Now, for the first time, a group of researchers from the University of Waterloo in Canada actually studied how the back moves during sex, adding some hard data to support, and in some cases, debunk, the common advice doctors give their patients.

The first phase of this research focused on how the spine moves in a normal, healthy male during sex. To do this, lead researchers, Natalie Sidorkewicz, MSc, and Stuart McGill, M. PhD, recruited 10 heterosexual couples who did not have back pain.

Then they wired them with reflective sensors and told them to “move as naturally as possible” in five different sexual positions: two versions of the missionary position, two versions of the “doggy-style” position, and “spooning” or side-lying (the most common position recommended for people with back pain).

The researchers analyzed the data and identified the positions that were most “spine-sparing”—involving less movement—for different types of back pain.

Some people—and this is more common with age—experience back pain when they sit or bend forward. This is “flexion-intolerant” back pain. The best position for the flexion-intolerant is the quadruped or a missionary position with the male on his hands.

A second type of back pain is called “extension-intolerant,” which means that lying on the back or stomach is painful. For this type of back pain, spooning may be a better position.

For some people, any movement causes back pain, and for these “motion-intolerant” types, sex remains challenging. In general, however, movement (and pain) is lessened when it is shifted to the hip and knee, as in the quadruped position when the female is on her elbows.

With any of these positions, small adjustments—whether a person is on elbows or hands, for example—significantly changes the amount of back movement involved.

The best option for the person not controlling the movement (the females in this study) is to keep the spine in a neutral position, by supporting the small of the back with a pillow in the missionary position, for example.

A chart illustrating the best position for different types of pain is here.

Future research will focus on female back movement during sex and how the spine is affected by orgasm. The researchers also want to study the effect of various positions for actual back pain sufferers.

All this is the beginning of good news for people with back pain. Previously, medical recommendations have relied on “conjecture, clinical experience, or popular media resources,” according to the University of Waterloo study. Hard data is a welcome addition.

Researchers also hope their work will spark more dialog between patients and health care providers about sex, now that practitioners have real research to refer to in discussion with patients with back pain.

I have a lot of conversations with women about sex, given my line of work. And, because of that little pink “Ask Dr. Barb” button on our website, I get some cryptic emails, too. Sometimes I have to read between the lines, both in person and online, to understand what the situation—and therefore the question—might be.

One recent email referred to male partners who were not especially “gifted.” As I think about it, I suspect that my correspondent was wondering about her own orgasm—or her failure to experience it. That’s not the topic we corresponded about, since she went on to ask a different question, but because I’m sure that woman is not alone, let me lay it out here.

In spite of the passionate scenes we see in movies, most of us—70 percent—don’t experience orgasm during intercourse without additional stimulation. For most of us, it’s the clitoris that’s the key to orgasm, and most positions for intercourse just don’t provide enough stimulation. There are other sources of stimulation that can lead to orgasm—some of us have very sensitive nipples, for example, and some of us have found success with the G-spot.

It’s rare for a partner, whether “gifted” or not, to be psychic; and most women I know would prefer that their partner not be too widely experienced in the varieties of women’s responses. And that’s why I encourage women to know their own bodies, exploring either on their own or in the presence of their partners (many of whom find the experience quite erotic, by the way). Vibrators have proven to be very effective in clitoral stimulation; adding internal stimulation is helpful for about a third of us.

When you find what works for you, you can give your partner some suggestions, which will be much appreciated. (If, by the way, you’re wondering whether you’ve experienced an orgasm, keep exploring. You’ll know when you have.)

Ninety-six percent of us can experience orgasm. Be assured of that and relax. Being focused on that goal can inhibit your ability to achieve it. And let’s affirm one more time that sex can be pleasurable without orgasm, too, for the intimacy you share with your partner, for the feeling of wholeness and power it gives you.

Another email exchange—with a woman who experienced her first orgasm at 70—confirms that it’s never too late.

If you’re a regular reader of the MiddlesexMD blog, you might think I’m a broken record on the topic of the dearth of pharmaceutical tools to address hypoactive sexual desire disorder (HSDD). That’s because I am. I don’t know how else to respond to where we are, except to keep talking about it, to make sure we’re all sufficiently aware—so we can all be clear, when the subject arises, about what we want and need.

As I encourage us all to recognize, women’s sexuality is complicated from the start, and becomes more so as we enter perimenopause and menopause. Our sexuality is an intermixing of the physical, psychological, and emotional. It often takes some experimentation for women to get back on sexual track, sometimes because it’s not clear whether a physical problem is in the lead or it’s really stress or a relationship issue that’s diminished desire.

In that experimentation, I prefer, as a physician, to start with the simplest steps first. That may mean adding a lubricant or a vibrator to a woman’s bedside table; it may mean using dilators for a time. But also as a physician, I appreciate knowing that there are pharmaceutical options in my repertoire, too, to help a woman get unstuck.

So I follow the news about drugs in development, and about their progress in getting approved for use by the FDA. Earlier this summer, I received an update from the Board of Directors of the International Society for the Study of Women’s Sexual Health (ISSWSH). They wanted to be sure that we’d seen an ABC News story on Flibanserin, which is still stalled out on appeal, subject to additional study.

“No single drug will ever be a cure-all in sexual or most other conditions, let alone effective for 100% of appropriate patients,” the ISSWSH statement read. “But that is never the standard by which biopsychosocial drugs are approved.” The news story also questions whether the standards for drugs for women’s sexuality are different from those for men. It compared side effects of dizziness, sleepiness, and anxiety to those listed in “iconic Viagra commercials, such as nausea, diarrhea, and the risk of erections lasting over four hours.” The reporter suggests that the bar seems higher for drugs for women.

I’m not in the room for the FDA discussions, so I don’t pretend to know whether there’s bias at play. I simply point out that there are 25 FDA-approved medications for men’s sexual dysfunction, and none that address HSDD for women. None. As a physician, I’m conscious of that void whenever I’m talking to a patient who misses her sexual self.

What do we do? Keep talking about it, even if we sound like broken records. And, if you haven’t already, you can sign on to the ISSWSH Wish Petition. The number of names listed does help to communicate the importance of this issue to women and the men who love them—as well as to the health care providers who serve them!

We received this submission from UK-based kindred spirits, looking to maintain intimacy for women–and their partners–just as long as they choose.

Erectile dysfunction affects millions of men in the UK and there is often embarrassment surrounding the issue. Erectile dysfunction is when a man cannot get or maintain an erection which makes engagement in intercourse impossible. In fact, the NHS estimate that 50 percent of men aged between 40 and 70 will suffer from erectile dysfunction at least once in their life.

The main causes of erectile dysfunction are both psychological and physical. Sometimes hormones can be the problem, as can high blood pressure and high cholesterol which cause the blood vessels to narrow and sometimes erectile dysfunction can occur as a result of surgery or an injury. Not only can erectile dysfunction be a symptom of other health problems, it can also be the cause of psychological effects. Erectile dysfunction can have a serious effect on a man’s mental well-being, because it can damage his self-esteem. However, the relationship between erectile dysfunction and psychological issue can be seen as a vicious circle; not only can erectile dysfunction be the cause for reduced self-esteem and depression, but anxiety and depression are also listed as common causes of erectile dysfunction.

It’s not just men who are psychologically affected by erectile dysfunction, either. Women can get emotionally hurt when their partner is unable to get an erection or maintain one, because they blame themselves and think they could be doing something differently to help their partner. Sometimes women feel rejected when their partner suffers from erectile dysfunction, assuming
that their partner can’t get an erection because they are not adequately aroused.

Of course this does not help make the situation any less stressful for the male suffering from erectile dysfunction and the situation is often made worse. Relationship problems can often occur as a result, because tense situations arise and couples are too embarrassed to talk about the issue.

According to clinical psychologist Mark L. Held, PhD, the best thing to do is talk about erectile dysfunction before it becomes a strain on the relationship. Held says discussing the issue is crucial because:

“Almost all men have erectile dysfunction at some point… it’s how they deal with it that counts.”

Sex therapy can be an effective solution for couples whose relationship is suffering as a result of erectile dysfunction. A qualified therapist can help couples talk through the issues that have arisen, as well as help them identify and work through the psychological reasons that are causing
it in the first place.

There is a plethora of medications that can help against erectile dysfunction. Perhaps the most famous one is Viagra, but there are now many more that work better for different patients. In any case, sufferers should discuss the issue with their doctors to determine if and which medication is appropriate for their case.

For some help in responding when ED’s been countered, see our blog post, “He’s Got His Groove Back. O Happy Day?”

Sjogren’s is an immune system disorder most commonly identified by dry eyes and dry mouth, but vaginal dryness is among the additional symptoms. For a vaginal moisturizer, be sure you’re starting with a product designed to be effective for that purpose (and Yes and Emerita are among the favorites we offer). Normally moisturizers are used twice a week, but with a condition like Sjogren’s, you may increase that frequency.

For a lubricant, I’d recommend a hybrid (like Liquid Silk) or a silicone (like Pink). The silicone lubricant will last longer and feel more slippery, which usually means less discomfort. The hybrid, which has some of the benefits of both water-based and silicone, may be your choice if you use a silicone vibrator. If you want to experiment to compare lubricants that are water-based, hybrid, and silicone, we offer a Personal Selection Kit so you don’t need to invest in a full-size bottle just for a test!

You have plenty of options in managing your comfort and Sjogren’s! I wish you the best of luck.

You describe hot flashes and night sweats that began after a hysterectomy to reduce breast cancer risk. You’re right that the symptoms can be prompted by your sudden entry into menopause (through surgery) as well as by the prescriptions intended to deplete estrogen in your system. You are, as you know, not alone in facing this challenge!

I always start with lifestyle factors, which can lessen symptoms for anyone. You may be able to identify triggers (like caffeine, alcohol, spicy foods, or sugar) that you can avoid in your diet. Dressing in layers is a must for many of us. Now is the time to exercise regularly; women who do so may have fewer and/or less intense hot flashes.

Reducing stress—or learning new tactics to manage it—is helpful if you can do it (I know life doesn’t always cooperate). Paced respiration is a technique to ease the intensity of a hot flash when one occurs: Breathe deeply and slowly, inhaling through your nose and exhaling slowly through your nose or mouth. There’s also a biofeedback technique to slow the heart rate, which may lessen the hot flash intensity and duration (because an elevation of heart rate is part of the physiology of a hot flash).

Acupuncture has been very helpful to a number of my breast cancer patients in managing hot flashes.

Beyond that, we haven’t seen a lot of success with alternative medications and complementary therapies. Those that have been tried include isoflavones (found in soy but not recommended for breast cancer patients), black cohosh, chaste tree berry, ginseng, dong quay, red clover, yarrow and others. For those that have been investigated and undergone careful scrutiny, the results are disappointing; there is limited scientific evidence for most herbal options. That being said, placebo has at least a 25 to 40 percent response rate in nearly every study, so if you can determine that an herb is not harmful (check with your physician) I do not discourage women from trying herbal preparations. I wish we could make a recommendation knowing we are in fact offering beneficial outcomes, but that just hasn’t been so for these options.

There are some non-hormone prescription options that have favorable effects. Just in the past year the FDA approved Brisdelle specifically for the treatment of hot flashes. It cannot be used with Tamoxifen, but as a very, very low dose of paroxitene (generic for Paxil), Brisdelle is well tolerated with minimal side effects. The anti-hypertensive medication clonidine has been shown to reduce hot flashes for some women, as well as gabapentin (generic for Neurontin). Other antidepressants can reduce hot flashes as well: venlafaxine (generic for Effexor), paroxetine, and fluoxitene (generic for Prozac), and escitalopram (generic for Lexapro). All of these have a modest benefit to hot flashes. They each have the potential of side effects, so a discussion with your provider is helpful in determining an option best suited for you.

Good luck, and the good news is that time will work to your advantage for the hot flashes. This too shall pass—really!

I’m a gynecologist. I talk about sex and body parts all day long, and I have for 25 years.

I guess I take a certain amount of openness for granted. I see intimacy as a cherished part of relationships, and sexuality as a natural part of overall health. So I’m a little surprised more people aren’t talking about both!

That the conversations aren’t happening was apparent last week, when I spent a few days in the exhibit hall at a major conference for nurse practitioners. Every time I turned around, another woman (mostly, but also some men) was saying, I’m so glad you’re here! I get questions all the time, and I don’t know where to go for information or where to send women for resources.

At our MiddlesexMD exhibit, we had a cross section of our products on display, and found plenty of curiosity about some of them. Kegel tools probably led in prompting conversations, with vaginal dilators following. One woman nurse practitioner brought her husband by to show him, up close and personal, the first vibrators he’d ever seen.

There were a few gasps and a little blushing, but once our conversations got underway, I’m hopeful that these health care providers began to see our “toys” in a different light. Because yes, there are symptoms anyone in perimenopause or menopause can recognize: vaginal dryness and less sensation. And yes, many of us see intimacy as a part of our relationships that we’d hate to lose. And most definitely yes, there are things we can do—products we can use—that help us to compensate for changes and maintain (and even regain) our sexual health.

So, to the woman who came to our exhibit saying, “Are those what I think they are,” the answer is yes. And no.

Beyond being “sex toys,” these products are also tools for increasing blood circulation, strengthening muscles, and nourishing tissues. By keeping sex not only possible but satisfying, they’re reducing stress, improving cardiac health, combating pain and depression, and burning calories. If we think about them in that light—practically as medical devices—perhaps we’ll be more open-minded about adding to our repertoire.

There was plenty that was encouraging, even energizing, about my conversations last week. There are thousands of nurse practitioners—and other health care professionals—who are willing and prepared to talk. Every woman can help by initiating the conversation when they have concerns about intimacy or their sexual health.

You don’t have to talk about sex every day, as I do. Just don’t be shy when it matters.

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