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Keep on Learning

Remember in middle school (we called it junior high in those days) when the boys and the girls were shepherded into separate rooms for those awkward films? It might have been presented by the gym teacher or the guidance counselor; maybe your school was large enough to have a health teacher who presided as we were introduced to the signs and effects of puberty—and the dangers of acting on urges.

My conversations with women lately have reminded me that while we take great pains to introduce our younger selves to their biology, we don’t quite follow through. In the sex ed I’m familiar with, the story stops with the fertile years. We don’t introduce the full cycle we can all expect to experience if we only live long enough.

Yes, breasts bud and menstrual cycles begin. We have children, or we don’t; we may have illnesses or surgeries. At some point, the cocktail of hormones shifts, and the parts of our bodies once prepared for reproduction begin to change once more. Our periods become unpredictable and eventually stop (a year without defines menopause). Our tissues become dryer, more fragile, less elastic. Without care and attention—and often in spite of them—our vulvovaginal tissues atrophy, which means they actually shrink.

And where do we learn this? Not in a gym or a cafeteria with a hundred of our same-sex classmates! For too many of us, we learn it only through our own experience, at a point in life when there aren’t many people we’re talking to about sex. We’re tempted to think this is an odd thing that’s happening only to us. We’re a little embarrassed, maybe a little ashamed.

There’s so much more common about our experience than most women think! If only there were a middle school for midlife, so we could all get together and learn about this next phase of physical transitions. As we thought (or it was hoped we were thinking) back in the original sex ed, knowing what’s ahead is the first step in making good decisions and taking charge of our own sexual health.

I haven’t yet figured out where to offer my midlife sex ed classes, or how to get busy women to attend! So I’ll keep having conversations with women one on one in my practice and through the MiddlesexMD website. I hope you’ll be having conversations, too, because even without the awkward films, we’re all in this together.

Let’s first acknowledge that women—and men, too—come to sex with a host of different backgrounds, value sets, cultural expectations, emotional foundations, and experiences. It’s very difficult, given that variety, to assert that anything is or should be true for every woman.

It is theoretically possible to have a strong physical attraction and enjoy sex with little emotional intimacy involved—whether we are men or women. There are differences between us, though: Research suggests that for women there are six neurotransmitters involved in sexual activity, and that the areas that “light up” in our brains with sex are completely different from men’s responses. Women release oxytocin with sex, a very strong bonding hormone; men don’t.

Cultural stereotypes may exaggerate the differences between men and women when it comes to sex, but the science is there to prove there are differences.

Among the women in my practice and in the rest of life, I observe that women often go into sexual experiences with an expected outcome that includes some emotional connection. Most of the women I see desire emotional intimacy as a cornerstone for their enjoyment of physical intimacy. And the study I recall that went the furthest in qualifying sexual enjoyment (“A Portrait of Great Sex“) implied emotional intimacy as intertwined with physical intimacy.

All of that said, I come back to the fact that women come to sex with enormous variety of experience and expectation. As long as she is caring for her own emotional and physical safety and health, each woman can choose, I hope, the right combination of emotional and physical intimacy.

What you ask about specifically is your clitoris, which, along with other genital tissues, does typically shrink with the loss of estrogen—whether through menopause or some other medical event. Because you’re under 40, which is young for what you’re describing, I’d encourage you to express your concern to your health care provider and have a thorough pelvic exam. The exam will be helpful in finding out whether there’s another vulvar condition causing the tissue changes—or whether you’re experiencing normal changes.

As we lose estrogen, we do face something of a “use it or lose it” proposition. That is, circulation and stimulation keep our genital tissues healthier; left to their own devices, they’ll atrophy. If you don’t have a partner right now, a vibrator is a great choice to provide stimulation and increased blood supply to the area. Maintaining your health means you’ll be ready for intimacy when—just when you least expect it—a relationship emerges!

That sounds like a bad riddle, right? Like one I heard on NPR last week: What goes up a hill and down a hill but doesn’t move? The answer to that one is a road. And the answer to what subtracts more than it adds is sex.

Here’s the disturbing—but not, when I think about it, surprising—statistic I ran across this week, courtesy of colleague Sheryl A. Kingsberg, a PhD and chief of the Division of Behavioral Medicine at the University Hospitals Case Medical Center: “When sex is good, it adds 15 to 20 percent additional value to a relationship. When sex is bad or nonexistent, it plays in inordinately powerful role draining the relationship of positive value—about 50 to 70 percent!”

I was so struck by that statistical picture, I’m on the trail of the original research to understand more. But in the meantime, what I know from other studies—and my own experience and conversations with women—suggests that’s about right.

Let me first say that good sex doesn’t automatically make a relationship good. And a good, loving relationship doesn’t automatically mean that the sex will be good. But if I think back to a study done a couple of years ago, “The Components of Optimal Sexuality,” I’m reminded of how many of the characteristics of good sex are also characteristics of good relationships.

I won’t revisit the whole list, because you can read the series of detailed blog posts we did on each of the components. But here are just a few that come to mind in this context:

  • Being present. It’s so easy to take our partners (and, of course, others in our lives) for granted. Truly paying attention to one another—today—is a great gift.
  • Connection. When we feel connected to our partners, intimacy comes naturally (especially when we’re overcoming obstacles together). If you’re feeling “together but alone,” there are steps you can take.
  • Authenticity. At this point in our lives, I find that many of us are more willing than ever to own what we think and feel. Whether we’re in longstanding or new relationships, this helps us to be ourselves—and to be open about what we like and need, in the bedroom and the rest of life.
  • Vulnerability. Having sex is perhaps the ultimate act of making yourselves vulnerable to each other. What a reinforcement of the bond that a couple has with each other!

If those parts of your relationship are important to you, too, you’ve got more reason to understand how to stay healthy and be intentional about nurturing this part of your life.

Itchy beyond words. Crotch of underwear rubs painfully against labia. Sensation of being on the receiving end of a vulvar wedgie. Feels like tiny razor blade nicks in my vagina during intercourse without lube or adequate foreplay. Also difficulty with penetration.

Doesn’t that sound awful? If that were you, I wouldn’t be surprised that you’re not thinking about sex. Just as awful, about half of us think that vaginal dryness is something we just have to live with—and about the same number of us are hesitant to raise the topic with our doctors.

The truth is that vaginal dryness does not need to end the intimacy you have with your partner—or the afterglow you experience yourself after sex.

First, a word about what’s happening: Yes, it’s likely hormones. As estrogen levels decline, the vaginal lining changes. It becomes more delicate and less stretchy. There’s less lubrication and less circulation. Vaginal dryness is a typical first sign of vaginal atrophy, when vulvo-vaginal tissues shorten and tighten. It’s common; you’re not alone, and you’re not deficient.

If you’re just beginning to notice some discomfort, you can take the easy step of adding lubricant to your foreplay. Lubricants come in three types: water-based, silicone, and hybrid. My patients with dryness issues typically like the silicone and hybrid best, because they last the longest without reapplication, and because they seem just a little bit slipperier to some. Lubricants are made specifically for safe use on and in your vagina; if you want to experiment with a few, you can try our Personal Selection Kit (and read more about it here).

Next, you can add a vaginal moisturizer. While lubricants provide temporary comfort, reducing friction during sex, moisturizers work to “feed” and strengthen vaginal tissues around the clock. Moisturizing here is just like moisturizing your neck or your face: You have to be faithful! I recommend application at least twice a week. Moisturizers need to be placed directly in your vagina, which can be done with an applicator or a clean syringe you reserve for that purpose.

For some women, these two products—and the right amount of foreplay—are enough to make a difference. If they don’t do it for you, please talk to your health care provider, even if you think it will be awkward: Your sex life is important! There are localized estrogen products and a relatively new oral medication (called Osphena) that may be helpful for you, but you’ll need a consultation with your physician and a prescription.

This isn’t the end; it’s only a transition, which we as women have a lot of practice with. Take heart and take charge!

Surely this has happened to you: You read one article, and it leads you to another. From that second article, you’re pointed to another. Before you know it, you’ve spent an hour diving into a topic that wasn’t quite on your to-do list.

Today I’m glad I did. The first article was “A Good Sex Life Can Help Older Couples Cope with Illness and Other Difficulties,” in the Washington Post (a long title, but you don’t have to read the whole article to get the point). That led me to the full research in The Journals of Gerontology. And a reference in the full research prompted me to seek out an earlier article by researcher Adena M. Galinsky, published by the National Institute of Health.

That article, published in 2012, is called “Sexual Touching and Difficulties with Sexual Arousal and Orgasm among U.S. Older Adults.” The author defines “sexual touching” as “non-genitally focused sexual behavior,” including “but not limited to, kissing, stroking, massaging, and holding anywhere from one part to the entirety of a partner’s body.”

This, ladies and gentlemen, is foreplay, and what I love about this article is that it presents empirical data of its importance! With more foreplay, both men and women experienced fewer “difficulties with orgasm, sexual pleasure, and sexual arousal” and more physical pleasure in their relationships.

We all have “sexual scripts,” Galinsky says, which we learned growing up and tell us, without our thinking about it, how to be intimate. Depending on where and when you and your partner learned about sex and romance and relationships, your scripts may not include much sexual touching. If that’s the case, it’s time to call “Rewrite!”

Having the time and the cues of desirability, safety, intimacy, and arousal are critical to us in midlife. If we don’t have them and still expect our bodies to respond as though we’re 20, we’re setting ourselves up. And we can fall into the downward spiral I’ve talked about before: We’re uncomfortable or unsatisfied when we have sex, so we’re unmotivated for a repeat performance. Because we’re not having sex, it’s less comfortable next time we try, so we put it off longer. We may begin to wonder if there’s something wrong with us, which is the opposite of feeling sexy. And before we know it, we’ve abandoned a part of ourselves that made us feel loved and lovely and powerful—and our partners quite happy!

You can talk to your partner about a collaborative revision of your “sexual scripts.” You can share this guest post by a “man friend” of MiddlesexMD, or this “Open Letter: How to Really Turn Me On” to start the conversation. And then, you know, one thing can lead to another. In a very good way.

A couple of weeks ago, I talked about an article I’d seen about how sexual intimacy is linked to marital happiness. The research, by Adena M. Galinsky and Linda J. Waite, found that continued healthy sex-lives help couples dealing with physical illness, especially chronic health problems.

Couples who had sex frequently (and sex was defined broadly—it didn’t need to include vaginal intercourse) were more likely to say they had a good relationship.

This is, of course, a chicken and egg: More sex doesn’t automatically make a relationship good. It’s more likely—and perfectly reasonable—that an unsatisfying relationship will include less sex. And the women I meet through my practice as well as the rest of life show me that this is often a time when our relationships get some re-evaluation.

Sometimes it’s the empty nest, and the change in schedules and priorities that comes with it. Sometimes it’s retirement, for one or both partners, which means a lot more together time. Sometimes it’s the stress of caring for aging parents along with everything else. Whatever the prompt, when some of us look at our relationships, we say, “Is this really what I want?”

So it was interesting to me to read the details of the Galinsky Waite study, to see how they measured the quality of relationships. These are the questions they asked:

  • How close do you feel your relationship with your partner is?
  • How often can you open up with your partner if you want to talk about worries?
  • How often can you rely on your partner for help with a problem?
  • How often does your partner make too many demands?
  • How often does your partner criticize you?
  • How happy is your relationship with your partner?
  • Do you like to spend your free time together, separately, or some of both?
  • How emotionally satisfying is your relationship?
  • How often does your partner get on your nerves?

If you’re feeling some vague discontent, those questions might help you with a conversation with your partner—or with a couples therapist if you decide some outside perspective and coaching would be helpful. If you’re feeling angry, or resentful, or isolated in your relationship, it’s no surprise that you’re not feeling sexy.

And you deserve to.

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