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Archive for September, 2010

A declining interest in sex as we age is typical for women, but many face a couple of additional factors that are really big: 1) It is painful; and 2) the event itself may not be particularly engaging. Is it any wonder that there isn’t much motivation to participate?

If you have pain, you need to find a practitioner who can help solve that issue. There is almost always a solution for pain with intercourse. NAMS (The North American Menopause Society) is a good resource for finding a certified menopause practitioner if you feel your provider isn’t able to find a solution–or you’re not comfortable discussing the issue with him or her.

The other issue is more difficult to address. After years, maybe decades, of a less-than-fulfilling sexual relationship, it is hard to reinvent, but most women would agree it is worth trying. For some menopausal women a great sexual relationship doesn’t even need to include vaginal penetration, but that takes a caring, nuturing partner.

Your partner needs to understand that romance and emotion are key to improving your libido–and you need to feel confident that you deserve that… because you do. For some women testosterone, in addition to that intimacy and foreplay, can make a remarkable difference in libido. Again, finding the right provider to investigate that option would be beneficial for you.

Some women have told me that visiting our site with their partners has been helpful. You might review the bonding behaviors together to start a conversation about what kind of foreplay and attention you need for a better opportunity for comfortable–even satisfying!–sex.

Your lack of interest is not in your head! I have yet to see a woman with pain with intercourse for which I couldn’t find some cause and some solution options. Things to explore with a menopause care provider are atrophic vaginitis, vulvodynia, or vaginismus. Sometimes localized estrogen is required in addition to HRT to fully estrogenize the vagina.

There are solutions out there! Please explore them fully. Good luck, and don’t give up!

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I had a call the other day from a friend who’s been a widow for several years. “I’ve found someone!” she told me, with just the slightest quiver in her voice. “I’m so excited I can hardly concentrate at work.”

Of course I was happy for her — and happy that she called to set up an appointment with me for an exam in anticipation of resuming her sexual life. “I think everything’s going to be okay,” she said, “but I think I might want to come in and see you first so you can tell me for sure.”

She did come in to see me and I was glad to be able to reassure her that, from a physical perspective, she was good to go. If I am able to place two fingertips in a patient’s vagina without causing pain or discomfort, it’s a good bet that she’s going to be able to have intercourse comfortably.

But more than a few post-menopausal patients who come to my office have been astonished to discover that they can’t pass the two-finger test. Their vaginal walls have narrowed and thinned over a period of time without regular intercourse, and I have to tell them it’s going to take some work to get back into a condition where penetration will even be possible, let alone comfortable.

I run into this fairly frequently with women who are widowed and divorced at our stage of life. They are grieving or angry — or both — and, without thinking too much about it, decide that their sexual days are behind them. Don’t need to worry about that anymore! But, as my ecstatic friend can attest: You never know. Surprises happen, and when they do, it sure would nice to know that your body’s ready and able to experience the pleasures of intercourse.

It’s one of my biggest concerns for single women our age. If you’re 30 when you divorce and 40 when you want to take it up again, there’s been no lost ground. But if you’re 50 and decide to resume sex at 60, it’s a very different story. You find yourself in a new relationship, you’re ready to be intimate, but your vaginal “architecture” has changed. It can be a very unhappy surprise.

Physical therapy with vaginal dilators can help to restore capacity for intercourse, but it’s much simpler — and more pleasant! — if you don’t lose that capacity in the first place. For all my patients and friends who are currently without partners, I recommend a “vaginal maintenance plan” that will help them keep their genitals healthy and ready for love: moisturize regularly; use a good lubricant; and experiment with a personal vibrator or dilator to preserve your capacity for penetration.

Because you never know.

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Estrogen-containing vaginal preparations are prescription only. If you haven’t tried lubricants and moisturizers, which are available over the counter, you might try those first.

Lubricants are designed for short-term effect, to make intercourse immediately more comfortable. They can be water-based, silicon-based, or a hybrid of the two.

Vaginal moisturizers are designed for longer-term maintenance of your vaginal tissues. They don’t contain hormones, so don’t require a prescription. They’re typically used every several days.

Localized estrogen, which is available as a ring or vaginal tablet in addition to cream, helps to increase blood flow and elasticity in genital tissues. If you’ve tried lubricants and moisturizers and haven’t yet been comfortable during sex, consider talking to your health care provider to see if localized estrogen or another hormone therapy might be right for you.

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Maybe I was naïve. We ran into some issues with the launch of MiddlesexMD.com earlier this year: We couldn’t advertise on a popular social networking site. An article we submitted was rejected because of subject matter. We were “ineligible” for a medical site designation.

And I took all that in stride, with some disappointment, as an entrepreneur, and some concern, as a physician trying to get the word out to women that sex is good for you and still possible and pleasurable, well beyond menopause. But I’m a parent, too, and I understand that there’s adult content that can’t just go everywhere.

But in the last week I saw a couple of articles (one in the New York Times, one on Salon) about Zestra and the walls its makers were hitting in trying to advertise. If you’ve missed the story, a commercial for Zestra Essential Arousal Oils was turned down by TV networks, cable stations, radio stations, and web sites. When it was accepted at all, it was slated to run in the middle of the night. Rachel Braun Scherl, the president of the company that makes Zestra, says, “When it comes to talking about the realities of women’s lives, you always have some woman running in the field…. There’s a double standard when it comes to society’s comfort level with female sexual health and enjoyment.”

As evidence, Rachel points to the advertising for Viagra and Cialis. And that’s when I start to think I may have been naïve. I remember the first time Bob Dole came on my television, during prime time, when my daughters were in middle school and still watching TV with me. It was a little awkward, maybe, to explain to them what “erectile dysfunction” was, exactly. Now they’re old enough to snicker with me (in a compassionate way—I am a doctor) when we hear “in the event of an erection lasting more than four hours, seek medical attention.”

So this gets me thinking. Why can we be so public about an aid to a man’s sexual satisfaction, but not aids to a woman’s? Is it because Viagra and Cialis are prescription products for a condition that’s been named a medical problem? In the case of erectile dysfunction, have we successfully separated the erection from sexuality? Because women’s arousal and satisfaction are more complex (remember why we love Rosemary?), is it too difficult to make that same separation? Or is there really still a double standard, with men’s sexual satisfaction ranking higher then women’s?

I’ll keep thinking. And, I’m sure, gathering anecdotal evidence on both sides of my questions. I’d love for you to join the conversation.

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I saw a patient this week who is in her early 60s, in great shape, and happily married to an attractive and generally healthy man also in his 60s. Recently retired from executive positions, they have been traveling to exotic — and romantic! — locales, enjoying fine cuisine and luxury accommodations.

They haven’t had sex in two years.

My patient told me that her husband had started having problems maintaining an erection since beginning medication for hypertension. After a series of failed attempts at their usual way of making love, they had given up trying to have intercourse. When I asked her if they pleasured each other sexually in other ways, using oral or manual stimulation for example, she simply shook her head.

This female response to male erectile dysfunction — not an unusual one by any means — intrigues me.

When the female half of an otherwise healthy, happy, heterosexual couple experiences a condition that prohibits penetration, she is typically eager to explore other options for sexual intimacy. But it doesn’t seem to work the other way. It’s like if he’s not going to get the ultimate end result — orgasm — then neither of them are.

I suspect what happens is that when men have difficulty performing, they start initiating sex less often. So once a week becomes once a month, and then there’s a problem and three months go by and it doesn’t work that time either, and — then it’s done!

What’s up with that, girls? Do partners with erectile dysfunction really lose all interest in any type of sexual intimacy? Or is it just hard  — for both of you — to change the game plan, the way sex happens, the way it starts, the way the “end result” is achieved or defined?

My guess is that many of these men would welcome their partners’ attempts to change things up, to experiment with new techniques and sensual aids that can enhance pleasure on both sides.

What’s your experience? What have you tried? What has worked — or not? Other women would love to learn from you!

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Are the medications you’re on behind your loss of interest in sex? Are they making it more difficult for you to reach orgasm? These are tough questions. On one hand, the answer is almost always “yes”: So many of the medications we take–including pain meds and sleeping aids–list lower libido as a potential side effect. On the other hand, the answer is also usually “no”: In my experience, the meds aren’t usually the primary cause.

With one exception. If a patient reports a notable change in her ability to reach orgasm and is taking medication for depression or anxiety, I ask if she’s on an SSRI.

The most commonly used antidepressants today, SSRIs–selective serotonin reuptake inhibitors (I know it’s a tongue twister)–are very effective in treating depression and anxiety disorders. Unfortunately, they also tend to dampen a woman’s ability to experience orgasm.

SSRIs–some of the most commonly prescribed are Prozac (fluoxetine), Paxil (paroxetine), and Zoloft (sertraline)–work by raising levels of serotonin in the brain, enhancing neurotransmission and improving mood. The “selective” part of the name is because SSRIs affect only one type of neurotransmitter–serotonin. But higher serotonin can lead to lower libido–and missing orgasms.

Of course, depression and anxiety all by themselves often lead to reduced interest in sex, so it can be hard to tease out cause and effect. But when a patient tells me she has lost desire or orgasmic function since beginning antidepressants, I often suggest that she consider switching medications.

Other types of antidepressants, like Wellbutrin (buproprion), act on dopamine neurotransmitters and typically have fewer adverse sexual side effects. In fact, studies suggest that increased levels of dopamine in the brain may actually facilitate sexual functions including libido and orgasm.

Sometimes bupropion is prescribed in addition to an SSRI, sometimes as a replacement. Doctors can often try different combinations and dosages until they find the prescription that treats the depression without robbing patients of their orgasms.

If switching isn’t an option or if changing the prescription doesn’t do the trick, there are other options. Even on SSRIs, a sluggish libido or elusive orgasm will respond to increased lubrication and stimulation.

Dealing with depression is hard. We don’t have to make it harder by accepting the loss of an important part of ourselves. If you’ve struggled with the trade-offs, let us know how it’s worked out for you.

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Isn’t it amazing how quickly things can change? You say you were tested as being mid-menopause. Blood work is accurate at assessing ovarian function on the day you’re tested, but it is miserable in predicting what may happen in the next weeks or months. An FSH level may come back 40 (suggesting menopause) on one day, but you may ovulate 6 weeks from now at have an FSH at 8. It’s really only over time that you really can better understand if this is the ‘new norm’ or transient. Perimenopause is known to have fluctuating symptoms; once in menopause, most women’s symptoms are more predictable.

To make sex comfortable again, I would start with a lubricant. I would try a water-based lube like Carrageenan or Yes. If using a lube makes you comfortable and doesn’t irritate the area, that can be a great, simple solution for now.

A warming lube can add some additional sensation for arousal and make orgasm somewhat stronger. Try Oceanus G Stimulating or Sliquid Sensations. Occasionally the warming lubes can be irritating if the area is sensitive, which is why I’d start with a non-stimulating water-based lube; then test a small amount of the warming lube to see if it works for you!

Good luck! I know you can have satisfying sex again.

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For the first 10 or 15 years that we knew her, we were not to call Elaine “Grandma.” At least and especially not in public. She was too busy attending to her coiffure and hosting wild parties for the American film productions in Rome to acknowledge this shift in her life. Holly GoLightly at the age of 55, she did not orchestrate or ask for grandmotherhood, so why should she assume the title?

Elaine is a footnote to this post, so let’s back up a bit.

It’s supposed to work this way: You have a baby, and your whole life changes forever. You prepare carefully, but nothing can quite ready you for motherhood. It shakes you up and places you down in another realm of life entirely. Your role as mother now trumps all the other roles you play. And all your family, friends, and neighbors understand, are happy for you, and supportive. Because we know what a mother is. Right?

But how is it supposed to work when your child has a baby? The shift in your roles is just as momentous, really, but less understood by everyone around you, and also by our ever-changing culture.

Sunday is Grandparents’ Day, and we thought we’d take a minute to ponder this change in identity that comes along, for many of us, close on the heels of menopause.

My girlfriends are going through this identity shift now. But I remember listening in when my mother and her friends became grandparents. They advised and consoled one another daily. For them there was anguish in being sidelined, or demoted. They expected to be involved, but they were not. Distance was the word of the day. The mom role, the central role of their adulthood, was somebody else’s job now, and being demoted while still in the room is nothing but awkward. That problem alone can be stunning (stun-gun set on paralysis).

This distant role was completely different than the role many of their grandmothers played. And our grandmothering will be very different from our mothers’. We just don’t quite know how yet. We are writing our new job descriptions on the job. Grandmotherhood will be whatever we make of it, shaped by family dynamics not entirely in our control. It can become the central role of your life, an enriching extra dimension. Or you can pull an Elaine, and pretend it never happened. (Her grandchildren thought she was fabulous, by the way.)

Our new role will need to encompass very well-developed mothering skills, fit bodies, pretty darned agile minds, and a new phenomenon for women our age: A lot of us are still enjoying just being girls. You know, being fit, fashionable, fabulous, garrulous girls. We are not prepared for the invisibility cloak that has long been the costume for the role of Granny.

I’ve had friends in tears, wondering whether they should cut their hair off and get a perm? Should they start wearing stretchy pants? Certainly no grandma should wear a thong anymore, right? And spikey heels are just… gross for grandma. Or are they?

These may not seem like pressing or important questions at the moment of bringing a new life into the world, a new generation into your family, but they represent a complete emotional upheaval. We’re moving into the upper ranks of our families. The end is not near, but you can see it from here. It’s awful at the very moment when everything should be wonderful. It’s emotional quicksand. Even the most stable among us can get trapped in it.

So. Got a girlfriend who’s a new grandmother? Our advice is: Pamper her. Make coffee dates, and give her your ear. Listen and attend as she carves out her own philosophy of grandmothering. This might be you some day. And then come back and tell us about what grandmothering means to the girl in you, will you? We would love to hear about your experiences.

To mark the day, we’ve developed a few special Grandma’s gift sets as a comfort and assurance for a grandmother in your life. We hope you like them–and she does, too.

Happy Grandparents’ Day!

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It’s a personal question, I know, but one I’m trying to be sure to ask my midlife and older patients who are newly single and sexually active.

Among women our age, sexually transmitted infections (STIs, sometimes called STDs for sexually transmitted diseases) are up and condom use is down. There’s a direct correlation.

Those of us who have spent the last 30 to 40 years in long-term monogamous relationships may not have even seen a condom in that time, let alone bought and used one. When contraception was the goal and a steady partner was the norm, we tended to choose less intrusive methods of protection–like the pill or IUDs.

Now, though, if you’re single and entertaining the possibility of a new sexual relationship, it’s time to get acquainted or reacquainted with the most effective means of preventing transmission of STIs like gonorrhea, HPV, herpes, chlamydia, and HIV: the venerable condom. Because it’s an actual physical barrier, and because it’s the easiest barrier to use, it’s the most effective option we’ve seen.

Of course you can buy condoms at your local drugstore or grocery store, but if you don’t want your kid’s best friend waiting on you, you may want to consider an online source. And if you’ve never bought or used latex protection before, don’t worry. We’ve sought out the right combination of function, fun, and discreet packaging so you can purchase from the comfort (and privacy) of your laptop, and our website offers basic instructions for using condoms.

(A parenthetical note: We know there are female condoms, which work just fine as a barrier for protection. But when we actually tested them as part of our product selection, we found them too clunky for us to be comfortable. We wouldn’t recommend them to our friends. But we’ll keep an eye on the options and let you know when something better comes along–or let us know if you’ve found a brand or a method that makes them your preference.)

A few more tips to help build your condom confidence:

– Keep a ready supply on hand–in a zippered pocket of your purse, in a drawer of your nightstand, or in nifty bedside storage like this tissue box we found with a private drawer. Scrambling around for that little packet in the heat of passion can cool things down in a hurry.

– Talk with your partner about condom use as soon as it seems clear that sexual intimacy is a definite possibility for the two of you. Agreeing that protection is essential–and deciding who’s in charge of making sure it’s there when the time is right–will ease anxiety and embarrassment for both of you.

– Incorporate condoms into your sex play and lovemaking. Application can be quite exciting in itself!

Finally, remember that not even your friendly condom offers 100-percent protection. In addition to insisting on a latex condom, NAMS (North American Menopause Society) guidelines for safer sex include choosing partners wisely and discussing sexual histories, getting an annual exam that includes testing for STIs, and making sure that your Hepatitis B vaccine is up to date.

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This is an important issue. At 49 you are ‘subfertile,’ but not infertile. You also can’t rely on rhythm, as there is no rhythm!

Barrier methods–condoms or a diaphragm–can work well, although they take some anticipation and planning. (If you’re in a new relationship, you might also consider the protection condoms provide against STIs, too.) If you choose that route, intravaginal spermicides in combination with the barrier will give you some additional coverage. The birth control pill, which is approved for use until age 55 or menopause, can still be an option. If you did well on it in the past, you would likely do well on it again; a careful health history would help make sure you are a good candidate. Now pills can be given in such a way that you menstruate much less often, or not at all. And one more option: There is an IUD on the market that lasts 5 years–likely to get you to menopause.

What you choose depends on your health history and your personal preferences. I’m glad you’re both enjoying your sexuality again and paying attention to this issue!

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