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We Can Each Decide

In October, I traveled to Washington DC to participate in a public meeting and scientific workshop on female sexual dysfunction. The meetings came about because questions had been raised about whether the FDA was paying enough attention to women’s sexual health, and whether they’d set the bar higher for products for women than for comparable products for men (think Viagra or the 25 other prescription drugs for erectile dysfunction [ED]). ABC’s 20/20 found the meetings newsworthy enough to do a segment on the pursuit of “pink Viagra.”

I’m a pragmatic, Midwestern menopause care provider. I see women who are at all points of the spectrum from mild discomfort to despair. I make recommendations and write prescriptions for quite a range of options—from use of lubricants and vibrators to off-label testosterone. I certainly know that there’s no one-size-fits-all solution, no silver bullet, no magic pill that’s going to make every woman’s sexual experience legendary—or even comfortable.

As we’ve said before, women’s sexual desire, arousal, and response are complicated. Emotional security and intimacy, sexual history, and relationship satisfaction can make an already-complex reality even more difficult to untangle. Every woman deserves an individual approach. Every woman deserves a health care provider who can capably represent the options for treatment, when that’s needed—including describing the benefits and drawbacks. Every woman deserves to make her own choices to govern her quality of life—including her sex life.

So I watch with interest the discussion that’s transpired since the October meetings, reinforcing the messages I heard there. Sexual dysfunction is as real for women as for men. Yes, it’s true that some women find relief without pharmaceuticals. Yes, it’s true that there’s a profit motive for pharmaceutical companies. Yes, there’s a hazard in “medicalizing” women’s sexuality; we are not only biological systems. Yes, it often seems “pharma” is marketing out of control; I know I’ve seen enough ED commercials to last me the rest of my life.

And yet—if the FDA is charged with looking out for all of us, why wouldn’t that include women? And if they’re concerned with all health conditions, why wouldn’t that include sexual health? And if a pharmaceutical option is developed, and found by fair and rational standards to be both effective and healthful, why shouldn’t that option be made available to women who might choose to take advantage of it?

The FDA is accepting comments from the public—especially seeking insight from women who’ve suffered from sexual dysfunction—until December 29. You can read the questions in the FDA’s document online, and then submit your comments by clicking on the blue button at the right on this page on Regulations.gov.

Your story can help make clear what #WomenDeserve.

Single? Sexual? Be safe

Recently, a friend and her sister visited a retirement community in our neighborhood. They chatted up several residents, including the sweet, 90-year-old widower who’d lost his beloved wife some months before. When they turned to leave, he asked the sister for her phone number. Since she is 50 and married, they laughed it off. Not long after, they heard that their elderly Don Juan had found himself a girlfriend in a nearby senior living community and was visiting her regularly. The anecdote is cute, but it also points to a larger reality. We are never too old to enjoy sex—that’s the entire premise of this website—but somewhere on the road to the golden years, single seniors have thrown youthful caution to the winds when it comes to safe sex. The result is that sexually transmitted infections (STIs), such as Chlamydia and syphilis, are spreading more quickly among people over 55 than among any other age group except 20-24 year olds, according to a 2010 report from the Center for Disease Control and Prevention (CDC). Even more alarming—one in four people with HIV/AIDS is over 50. In the Sunbelt, where large communities of seniors live, the rates of increase are off the charts: In two counties in Arizona cases of syphilis and Chlamydia among those over 55 rose 87 percent between 2005 and 2009; in central Florida, the increase was 71 percent, according to this article in Psychology Today. News reports use words like “epidemic” and “skyrocketing” to describe these increases. Medicare has begun offering free testing for STIs, but most (95 percent) of seniors remain unscreened. What the heck is going on here? What happened to all those lectures in responsibility and self-control we subjected our kids to? What seems to be happening is that we are, luckily, more long-lived and healthier than our forebears. We are also newly empowered with drugs to maintain erections for men and to make sex more comfortable and enjoyable for women. All the years of hard work, career-building, and childrearing are in the rearview mirror. Many of us find ourselves alone and treading tentatively back into this brave, new world of sex and dating. Add to this the sometimes freewheeling life in retirement communities (some of which are the size of small cities), which create hotbeds (no pun intended) of people of similar age and background—kind of like a college dorm. Trouble is, unlike kids in a dorm, seniors don’t have to worry about pregnancy and aren’t nearly as well-informed about the risks of unprotected sex. Condom use for those over 60 is the lowest for any age group (6 percent vs. 40 percent for college-age males). And condoms, in case you’ve forgotten, provide the only dependable protection against STIs, and even they aren’t effective against every sexually transmitted bug. Also unlike their much younger counterparts, older folks have a less robust immune system, so the chances of catching and spreading infections are higher. Plus, many STIs are asymptomatic, so the person doesn’t know he or she is infected—and that the STI is degrading the immune system even further. Finally, doctors rarely think to ask Grandpa about his sex life in the normal course of an exam, even if he has classic symptoms of an STI. All this adds up to a lively Petri dish of bugs circulating around the singles scene. Yet, prevention is so easy, and the cost of ignorance or of ignoring common-sense precautions is high. So, ladies, even if the prospective partner is someone you’ve known all your life, don’t assume you’re familiar with the intimate details of his sexual forays. Others have walked this path before—and are paying the price. Jane Fowler, 71, and founder of HIV Wisdom for Older Women, was infected with HIV by just such a friend when she was 55 and now advocates for more information and support for older women with AIDS. I’d suggest that if you’re dating, stick a couple condoms in your purse right with the lipstick. And get yourself tested if you’ve ever had unprotected sex. And read this series of posts about STIs on MiddlesexMD. The rule of thumb these days—better safe than sorry.

The Monogamy Drug

Looking for a warm and cuddly holiday season? Try a little oxytocin spritz along with the turkey.

Oxytocin is a hormone produced by the pituitary gland that activates certain reward receptors in the brain. It makes people compassionate. It makes women love their babies. It’s released during orgasm and causes couples to feel close to one another, thus its nickname, “the cuddle drug.” It’s also involved in addictive behavior, along with dopamine, another “feel-good” neurotransmitter.

A couple of recent experiments by Dr. Rene Hurlemann at the Bonn University Medical Center, however, suggest that oxytocin is a hormone that keeps men monogamous. Contrary to all kinds of evolutionary thinking, which would suggest that men would be driven to spread their seed in all directions, oxytocin appears to increase a man’s attachment to his sexual partner.

Monogamy is rare in the mammalian world. Only 3 to 5 percent of warm-blooded creatures pair up for life.

In his first experiment, Dr Hurlemann spritzed a few men with oxytocin and then introduced them to an attractive woman. The men in monogamous relationships stayed 6.5 inches farther away, on average, from the woman than single men did. When the same partnered men weren’t spritzed, the extra distance disappeared.

Dr. Hurlemann decided to investigate further.

In his second experiment, the male subjects, who were all in permanent relationships, were hooked up to a brain scan. First, they were spritzed with oxytocin, and then they were shown photos of their partner, of other attractive women, and of female acquaintances.

Sure enough. The parts of the brain associated with reward (the nucleus accumbens) and motivation (ventral tegmental area) lit up at photos of the partner, but not at the strangers or at female acquaintances. Under the amorous effect of oxytocin, these guys also felt that their partners were more attractive than photos of the other women.

The researchers hypothesize that this hormone that is released during close physical contact and that tickles our pleasure center reinforces monogamy this way: A man may limit the spread of his genes by sticking with one partner, evolutionarily speaking. But by sticking around to create a stable environment and helping to rear his offspring, he increases the likelihood that they will survive to reproduce. So, rather than feckless promiscuity, evolution takes a different tack and oxytocin is the carrot.

And while that’s a cold, scientific view of the situation, lots of touching, cuddling, massaging, and good old sex will keep your man’s pleasure centers (as well as your own) well-lubed and attached to the source of the goodies! In Dr. Hurlemann’s research, even the close presence of the partner was enough to release oxytocin, giving new meaning to the saying, “stand by your man.”

While you’re basting that turkey, keep in mind that our traditional holiday fowl is also high in dopamine, which might be well-poised to edge out Valentine’s Day (even in spite of the afternoon football) as the season of love.

I don’t know about you, but I care about a lot of things: my profession, my daughters, my friends, my community, my church. Because I care about them, I carve out time for them. My calendar is full, and so is my husband’s with the things he cares about. Often, our respective calendars send us in different directions.

When you’ve been together as long as we have, it’s easy to take each other for granted. We can forget to make time for the one you care most about—each other. We’ve talked before about the importance of putting sex on the calendar if you want better sex, and the same is true of intimacy (yes, there’s a difference, as our friend psychotherapist Mary Jo Rapini explains). To maintain—and deepen—your connection to each other, you need to set aside time in which you focus on each other and have fun together.

How you spend your date night is up to the two of you to decide, and that’s half the fun. I highly recommend that you try something different as a way of avoiding something called “habituation.” New things stimulate the mind, but over time the newness wears off and they become less and less engaging. That’s habituation, and it’s not great for a marriage. Date night is an opportunity to continually introduce the new and keep your relationship interesting. Attend a concert, take a class (cooking, art appreciation, Italian), or learn a new sport together. If money is tight, try one of these ideas:

  • Take the dog for a walk together, and let the dog determine the route
  • Go to a pool hall and play a game of pool
  • Dance to music that was popular when you first met
  • Go to the bookstore and pick out books for each other (no need to buy; the fun comes in talking about why you chose the books you did)
  • Any of Mary Jo’s other 50 ideas for cheap date nights

Regardless of what you choose, try to build in some time to talk either before or after the event. You’ll be surprised at how changing up the scenery and your activities will also change the nature of your conversation.

Date night creates a lovely cycle, really. Spending quality time together increases intimacy, which sets the stage for better sex, which further increases intimacy. So compare calendars and pencil in date night for the next six months. We’d love to hear what you choose!

You ask whether there’s an over-the-counter hormonal cream to restore vaginal elasticity. You’re finding intercourse painful and experiencing dryness.

Vaginal moisturizers will help to retain some moisture, but none of them will reverse the process—which is, medically speaking, atrophy given the loss of estrogen. The combination of moisturizers and lubricants will keep things comfortable for a while, but most women eventually need more.

Localized estrogen or the new pharmaceutical Osphena are effective; either requires a consultation with your health care provider. I’m not aware of any hormone-based medication available over the counter and, in fact, encourage a consideration of your medical history and current factors before use.

Films to Fuel the Fire

When I read the results of a new study showing that couples who watch and then discuss movies about relationships could reduce the likelihood they would divorce, it occurred to me that watching movies that include sex scenes might have a similarly positive effect on one’s sex life.

Friend, it does, and the reason is simple. Sitting down and watching a movie together on any topic—be it global warming, relationships, or sex—creates mindshare for that topic. And when it comes to sex, once you’ve created mindshare, the rest often takes care of itself.

We’ve talked about movies before, and our difficulty in finding them. I’ve been pressed for time the last month or so, so I asked a friend for some recommendations to pass along. She did some research—and a lot of movie-watching—on our behalf and recommends these three movies—movies with real storylines, acting, cinematography, and sex scenes that spring organically from the plot—guaranteed to remind you and your significant other that each of you are not only a spouse, parent, child, employee, or committee chair, but also a lover. (The comments are hers, but she also helpfully included links to New York Times reviews if you’d like confirmation!)

Y Tu Mamá También (NR, subtitles, New York Times review)

Julio and Tenoch, teenage boys in Mexico, can’t believe their luck when Luisa, a (slightly) older woman, agrees on a whim to go on a road trip with them to find a beach. Carnal relations ensue, some more surprising than others, but so does self-awareness. If, at the outset, the movie feels like a Mexican American Pie (the first sex scene occurs 20 seconds in, and the boys have a manifesto that includes “do whatever you feel like” and “don’t marry a virgin”), don’t be discouraged. It gets better. Luisa eventually tires of their immaturity and makes the rules, which the boys agree to follow. Her own manifesto includes “I pick the music,” “You cook,” and “You’re not allowed to contradict me.” Now that’s sexy! And there is a secondary storyline that hints at Mexico’s political and economic landscape seen from the car windows as the threesome cross the country. Sexy, funny, sad, and smart.

Sex and Lucía (NR, subtitles New York Times review)

This movie had me at the premise: Lorenzo is a writer; Lucía is an avid fan. She tracks him down, says she loves him and his novel, and moves in with him that same night. “I always liked people who tell good stories,” she says. “I trust them.” But should she? Lorenzo has a complicated past, and he’s also writing another novel; in the movie, you can’t always tell whether a scene is real or one he’s writing for his novel. No matter. Just enjoy the ride, particularly during the sweet and explicit (yes, both!) photo shoot L&L do together at 28 minutes, and a sexy (Lucía’s) and funny (Lorenzo’s) strip tease a few minutes later. A person might pause the movie there and get down to business with the one you’re with. Later you can resume the film, which gets a good deal darker, and try to untangle fact from fiction over a nice glass of wine.

The Lover (NR, New York Times review)

French Indochina, 1929, is the setting for this story about forbidden love between a French teenager from a dysfunctional family and a wealthy Chinese man who is besotted with her—but betrothed to another. The plot unfolds in a leisurely fashion, giving the story time to build. Looks are exchanged and fingers are tentatively touched, before they give in, but oh, when they do (38 minutes in for about 10 minutes), it’s a beautiful, aesthetically pleasing thing. The lovers are doomed, of course, but until the day of reckoning, they escape their own pain and inflict (primarily emotional) pain on each other. As with Sex and Lucía, to avoid having the plot spoil the mood, pursue your own agenda whenever you’re ready (if not by the 54-minute mark, then certainly after).

In fact, that’s good advice for watching any of these movies. Act now (and now, and ohhh, now); discuss later. According to research, both are good for your relationship.

And we’re always happy to hear from you about movies that stoke your flames!

You ask whether there’s a downside to using saliva as a lubricant. What makes it good for digestion makes it not so good as a lubricant: The enzymes that help break down food can be irritating to the delicate vulvar skin. As we lose estrogen, the vulvar tissue gets more fragile and delicate; what once was fine may become uncomfortable.

I also hear from many women that water-based lubricants don’t last as long as they’d like them to; they prefer a silicone or water/silicone hybrid lubricant for staying power through more foreplay.

That said, if it works for you and your partner, you can keep using saliva for some or all lubrication. Just be aware of the potential for irritation, and wash with a warm cloth after sex to minimize exposure.

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