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Archive for August, 2010

We’ve written before about our efforts to find erotica to recommend to our growing MiddlesexMD community (Hi there, community!). Our efforts are are purely pragmatic, you understand. By subjecting ourselves to hours of film, reams of erotica, searing our eyeballs with the online offerings — all off this sacrifice, all for YOU, we are looking to find the good stuff, the stuff that really does, in fact, heat up a grown woman. (Real life experience has a way of turning an awful lot of porn and romance into comedy, we have found.)

If you haven’t been following the posts here, let me explain briefly: In menopause, our circulating sex hormones dimish. That can sometimes, not always, lead to a drop in libido. Even when the libido is willing, becoming aroused enough for sex can take a little time and effort. We need to step in, do the work our hormones did for us when we were young.

An easy and inexpensive way to adjust to this new reality is to give ourselves more opportunities to have sexual thoughts — i.e., watching sexy movies, reading sexy literature, masturbating, wearing/doing sexy things.

Sexy literature… That’s my subject. I’ve been poking around just a bit, looking at collections of erotica, some of it good fun, much of it yawningly dopey. While I’ve been looking, I’ve been thinking about the guideline we established during our silly, foiled movie night: We much prefer a Great Story That is Sexy to a sex story.

Enter Jacqueline Carey. When I think of great stories that are sexy, she springs immediately to mind. Her New York Times bestselling Kushiel’s Legacy Series encompass great epic tales full of romance, politics, turmoil, grief, tragic loss, breathtaking triumphs, and plenty of sex. Most of the sex is great, some of it is frightening, but all of it is integral to the storyline. I love that. Her novels are fat and involving enough to keep me diving into them night after night. Sexy enough to keep me on the edge of my libido for hundreds of pages.

So, why not ask the author herself about “Great Stories that are Sexy”?

I put the question to her, and waited. At first, coming up with a list stumped Carey too, which made me feel a little better about coming up with so few recommendations of my own. She’s trolling for answers among her friends, too, but did come up with a starter set. Ms. Carey says:

*Try Diana Gabaldon’s “Outlander” series.
*For fun, sexy fluff, Janet Evanovich’s “Stephanie Plum” series.
*I don’t know how well it stands the test of time, but I thought Colleen McCullough’s The Thorn Birds was hella sexy and a good read back in the day.
*And check out Smart Bitches, Trashy Books for romance reviews. The genre’s come a long way in the past decades.

I feel as if we’ve finally got a foothold on Hot Lit. The birth of a canon. But it’s not really very big, is it? We need to feed this list. And for that, we need to hear from you. What do you think? Have you found writers whose work does it for you? Please share. We will keep adding to the list and will republish it as it grows. Those of us who read constantly need a steady supply…!

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She’s 54 years old. She’s spent most of her adult life in a long-term monogamous relationship. She’s just been diagnosed with genital herpes.

This happens more often than you might think.

Even I — who should know better! — have been guilty of age bias when it comes to testing for sexually transmitted infections (STIs, also called STDs, for sexually transmitted diseases).

In my former practice, when a 20-year-old came in presenting with symptoms (discharge, discomfort, irritation) that might indicate an STI, I would automatically screen her. When a 50- or 60-year-old came to me with the same symptoms, I was more likely to ask before I tested: “Is this a possibility?” If she said “no,” I tended to trust that. I was trusting my patients. They were trusting their partners.

Times have changed.

Over the past decade, STI rates among people 45 and older more than doubled. In April, the Centers for Disease Control and Prevention reported that senior citizens accounted for 24 percent of total AIDS cases, up from 17 percent in 2001.

Researchers point to climbing divorce rates at mid-life, the rise of online dating services, the increasing number of men availing themselves of treatment for erectile disfunction. And all of these are contributing factors, I’m sure. But in my experience, the most likely cause of the up-tick in STIs among women past their child-bearing years is lack of awareness and prevention.

If you know that pregnancy is not a possibility, why use a condom?

Unfortunately, the risk of contracting STIs — including syphilis, gonorrhea, genital herpes, HPV, hepatitis B, and HIV — does not end at menopause. In fact, sexually active postmenopausal women may be more vulnerable than younger women; the thinning, more delicate genital tissue that comes with age is also more prone to small cuts or tears that provide pathways for infection.

And — it’s not fair, but there it is — with almost every STI, exposed men are less likely to experience symptoms, simply because they don’t have the equivalent of a cervix and a vagina and the skin of a vulva. The kind, older gentleman who gave my 54-year-old patient genital herpes might honestly not have known he was infected.

These days, when a 50-or-60-ish woman shows up in my office with symptoms that point to a possible STI, I go ahead and screen. I’ll say, “I understand this is not a likely outcome, but I want to make sure I’m checking all possibilities.”

Worry about STI can be a real drag on sexual enjoyment. We’ll talk about what you can do to insure that contracting an STI is not a possibility for you in my next post: “When Was the Last Time You Used a Condom?”

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Thyroid disorders are not typically a significant factor for libido or orgasm. A bigger issue is expectations: The majority (probably at least 80 percent) of women cannot have and never have had an orgasm with intercourse alone. Most women need more direct stimulation. As we get older and in the absence of estrogen, having an orgasm without direct stimulation becomes even more difficult. It may not be realistic to expect to have an orgasm with intercourse or penetration.

A vibrator can be a great addition for that direct stimulation. You might want to try one with a warming lubricant, and see what happens! The Emotional Bliss vibrators (Womolia and Femblossom)  have more intense stimulation than some others on the market. I have seen some amazing results from women who hadn’t had an orgasm in years because of medications that interfere with orgasm or medical conditions that make orgasm more difficult. They were successful using these products, so give it a try and good luck!

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When you’re in perimenopause, we say that your hormone levels are, in general, declining. While they are declining “in general,” it’s likely that your levels of estrogen and progesterone are fluctuating erratically from day to day. Testosterone is usually more steady, not particularly fluctuating day to day or month to month. As a result, the mix of hormones changes, and for some women testosterone seems to play a more dominant role; one effect of testosterone is enhanced libido (it’s sometimes considered as part of therapy to restore sexual function).

This may explain what you are experiencing. You asked whether you should be tested for hormone levels. While it’s possible to measure hormone levels, and those measurements are accurate, the levels are accurate only for that hour or day and are not particularly helpful to predict what to plan on in the upcoming days or months.

I would say, enjoy the current state! I hope this is your ‘new norm.’

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In menopause, in the absence of estrogen, the vagina narrows and becomes more thin and fragile. Even when you are lubricated enough, the tissues have likely lost elasticity and can’t comfortably stretch with intercourse. Some light bleeding represents the “trauma” to those tissues and usually comes from near the opening of the vagina or the vaginal tissues themselves.

Using a vaginal moisturizer (like Yes, Replens, or KY Luiqibeads) would almost certainly help. It may also beneficial to use dilators to try to get back more caliber or capacity (dilators literally stretch the tissues gradually). You might also talk to your health care provider about vaginal estrogen, also known as localized estrogen, which may be of benefit to you in restoring elasticity.

Don’t give up! You can be comfortable again.

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The first thing I try to do with women who have both of these issues is to make sex comfortable. It is pretty hard to be interested in intercourse when you know it is going to lead to pain.

You might consider vaginal estrogen–estrogen that is ‘localized’ rather than ‘systemic’ and is delivered only to the vagina. This would require a prescription product. Or you need to commit to using a vaginal moisturizer consistently; this reintroduces moisture to the vagina on an ongoing basis.

Once sex is comfortable, then approach the issue of desire, which admittedly, is difficult. Yours might be a situation in which to consider using testosterone or buproprion, an antidepressant that can have the side effect of increasing desire. Engaging mindfulness and choosing sex is important to the sexual relationship. I review Basson’s research with patients, and remind them that desire does not play as big a role in women’s sexuality at this stage of life, so being intentional and choosing to engage is often necessary.

Find a provider you trust to talk through some of these issues and begin to explore options.

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Fortunately, the vagina is self-cleansing; it requires very little attention. The cells on the surface of the vagina naturally regenerate or ‘turn over’ on an ongoing basis. After intercourse, semen deposited in the vagina coagulates and then slowly liquefies again and is slowly secreted.

The top of the vagina is called the vaginal cuff when the cervix has been removed as a part of a hysterectomy. Not having a cervix doesn’t change that cleansing mechanism. Douching is disruptive to this natural cleansing process, disrupting the natural, healthy environment created by ‘good bacteria’ that belong there. In this case, less is best!

If you’ve had your ovaries removed or are naturally menopausal, the absence of estrogen means your vagina can benefit from a moisturizer placed inside the vagina. Yes, Replens, or KY Liquibeads are all great choices.

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I’m busy exploring the boundaries of a new phase of my life, brought on by an illness I’m managing. As illnesses will, it’s grabbed me by the collar, given me a big shake, and forced me to order my priorities. Also, it’s made me take a good look at Time.

Not in the Time-is-Limited sort of way, but in the nature of time. How fast it goes when we’re not paying attention, or when we are multitasking, when we’re playing our To Do lists in an endless loop in our minds. And how it’s actually possible to slow it down when we are paying careful attention to what we are doing.

I first noticed this in a not-so-pleasant way, as a young girl, in bed with horrible headaches. These headaches made me seek out darkness and quiet, and there was very little that medications could do to reduce the pain. I would lie for hours in bed in an eyemask, and the hours felt like days. I could think of very little else besides the pain, and time stood still.

It wasn’t until I tried meditation for the first time that I had the experience again — meditation made time stand still. This was in the 70s, and through the PBS television series, Lilas Yoga and You. Remember lovely Lilas? She ended most classes with Savasana. It was through her suggestions during savasana that I first learned to do a “body scan,” a way of getting in touch with my body through guided meditation.

In Body Scan meditation, you begin in a relaxed state, then use your mind to ‘visit’ every part of your body, noting how it feels, acknowledging pain or stiffness or itchiness, lightness or heaviness. It’s a way of checking in with your body, to connect with it. It sounds simple, but it does take practice. You can use body scan to help you relax. You can use it to help manage pain.

That work, inadvertently, taught me to manage the pain of my headaches from a very early age. I learned to separate the pain I experienced in my head from the rest of my body. I learned to relax into the pain, and keep it sequestered from the rest of my body. I thought I’d discovered some secret power, until I came upon the work of Jon Kabat-Zinn. What I’d stumbled upon through Yoga, he’d been teaching for years through his Stress Reduction Clinic at the University of Massachusetts Medical Center.

By now you must be asking yourself how any of this ties into midlife sex. Well, my secret power, savasana and body scan meditations, also taught me to relax and enjoy sex. I’ve always been a woman who wished for a body different from the one I had, so early experiments with sex were always fraught with efforts to conceal from my lover the parts of my body I didn’t like. That kind of distraction is a real barrier to intimacy.

Later, mindfulness techniques helped me to turn off the chattering brain brought on by an overstuffed life, at least during lovemaking.

Now, meditation helps me to stop the clock during lovemaking. It helps me keep the pain in my body contained so that it can’t overwhelm the experience of lovemaking. And it helps me to fully appreciate my one and only body. The only one I’ll ever have. Might as well love it.

If meditation can make time stand still, can stop the clock, might as well try it, right? If you’ve never tried meditation, you should know it’s not that hard to learn, and not that easy to master. It’s one of those things that just gets better with practice. And I know of no better or less intimidating guide than Kabat-Zinn, especially through his Mindfulness for Beginners program.

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