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Archive for October, 2010

I saw a headline that irked me in Salon.com’s Broadsheet a week or two ago. I couldn’t quite put my finger on why it bothered me until I wrote a post about the cancelation of the flibanserin project last week.

The headline was “Forget the pink pill, try a placebo.” The article opened by saying that “Researchers are desperate to discover ‘female Viagra,’ but Cindy Meston says sugar pills might hold the key.”

Meston, a clinical psychology professor at the University of Texas at Austin, co-authored a study, published in the Journal of Sexual Medicine. Reviewing data from an earlier clinical trial of a drug treatment for low sexual arousal, she noted that about one-third of the test subjects who were given a placebo instead of the actual drug reported they had more “satisfying sexual encounters” during their “treatment.”

The Broadsheet reporter takes these findings as “a reminder that in the rush to ‘treat’ female desire, there is one organ researchers can’t forget: the brain.”

That’s a conclusion I certainly agree with: Mindfulness influences our sexual behavior. More simply, when we think about sex, we have more sex.

So let me get back to what bothered me about that headline: Yes, the brain is a critical and often under-estimated part of women’s sexual response. But it doesn’t function alone. It requires and interacts with hormones, which trigger physical responses that depend on our circulatory systems and tissue health. And the brain functions within the context of our histories and cultures and relationships.

Suggesting that a placebo is the answer for every woman’s sexuality oversimplifies and trivializes the issue. (In most clinical studies, by the way, placebos get about the same 30-percent response rate, so this study isn’t remarkable by that measure.)

Meston herself isn’t proposing that placebos are the answer: “Expecting to get better and trying to find a solution to a sexual problem by participating in a study seems to make couples feel closer, communicate more, and even act differently towards each other during sexual encounters.”

That’s definitely the first step—to be intentional about taking control of and improving our own sexual experience, involving our partners when we can. Any pattern at all that helps to focus our attention will help—whether it’s a before-bed routine with a partner, a sensual lotion that’s part of our self-care, or even taking a sugar pill.

But if that’s not enough, it’s because while it’s in our heads, it’s also not in our heads.

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I’m a recreational runner, and before a run, I always spend a few minutes warming up. I’ll run in place and do some stretches, especially of my calves and ankles. Experts no longer say this is a must, but I do it anyway because I know that as I’ve grown older, I have tighter muscles and less range of motion in my joints. And I’ve learned that if I exercise and end up hurting, I’ll be more likely to postpone my next outing.

This cycle can also be true of sex. If you rush past the warm-up—foreplay—you may not have enough lubrication to make penetration comfortable. If sex hurts, you’re less likely to initiate it or to respond to your partner. The more time that passes without having sex, the more difficult it is.

Many couples have a long habit of foreplay, but If the women I talk to are representative of the larger population (and I believe they are), men don’t always get the connection. They are happy to skip the foreplay and sprint to the finish line. Early in the relationship, that might work even for women, who are more sexually complex than men, because excitement is high all the way around and it’s easier to get aroused. It might even fly during the “thirsty thirties,” when women’s sexuality peaks.

But during menopause and after, hormones work against us. Estrogen declines, vaginal tissues become thinner and more fragile, and circulation to those tissues decreases. The less stimulation your vagina receives—from sex with a partner or your own self-care—the faster those changes happen. We’re not kidding when we say, “use it or lose it!”

So after menopause, we need more to warm up. More real intimacy, more talk, more titillation. In short, more time.  The stakes are higher now. If we don’t warm up, it hurts. If it hurts, we don’t want it. If we avoid it for too long, it’s more and more difficult to have it. If any of this sounds familiar, it’s probably time to talk about it.

Because a little foreplay has gone a long way in the past, your partner might be puzzled when you suggest your lovemaking include more foreplay. He might worry he’s losing his sexual prowess. This is a great opportunity to explain how changing hormones affect your response to sex. If there’s something you’ve secretly been longing to suggest to him lo these many years, you can slip that into the discussion, too. It’s never too late for your partner to learn, and telling him what you need and why is a great first step.

How about you? Have you been able to change the patterns of sex with your partner? How did you approach it? How did your partner respond? We’d love to hear!

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It’s official. Boehringer Engelheim, the German pharmaceutical company, has shelved its plans to develop flibanserin. They’ve decided to focus on other drugs that “have better potential to make it to market.”

The pill’s been called “pink Viagra” because it was hoped it would do for women what other drugs have done for men with erectile dysfunction. I know flibanserin has been controversial. The drug was rejected by both an advisory panel and FDA staff, and much of the discussion about the project cancellation has focused on the negatives.

I don’t argue with concerns about Boehringer Ingelheim’s research or focus on marketing instead of fact-finding. But I do know that some of my patients who struggle with a loss of desire are desperate for more options that offer hope. They’re well-informed about their condition and their choices, and they’re fully capable of making decisions about the trade-offs between side effects and a return to a more complete sexuality.

The broader issue for me is the lack of focus on pharmaceutical options for women. Pfizer, makers of Viagra, canceled research into a female counterpart in 2004. Boehringer Ingelheim appears to be saying that it’s just too hard to follow through on a drug for women. What are the barriers? Are they cultural? Is male sexual satisfaction easier to talk about? To measure? To “monetize”?

As a physician, I want the most possible options to explore with my patients. Sometimes mindfulness, information, localized hormones, and tools like vaginal dilators and clitoral pumps are enough to change a woman’s life. Sometimes they’re not. I’m optimistic about ongoing research about testosterone for women’s sexual health, but I’d like to know that pharmaceutical companies see the issues we face as clearly and as important as I do.

Have you found a drug treatment that’s helped? Are you with me in thinking more options to consider is a good thing? Or would you rather pharmaceutical companies keep their focus elsewhere? Lots of voices will help them set their agendas.

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In an earlier blog post we reported on a study published last year in The Canadian Journal of Human Sexuality called “The Components of Optimal Sexuality: A Portrait of ‘Great Sex.’” Analyzing interviews with 20 sex therapists and 44 people who reported having experienced “great sex,” the researchers identified eight major components of “optimal sexuality” — sex that is “beyond functional, beyond positive and satisfactory, beyond good.”

It didn’t surprise me at all to read that the number-one component, the one that was brought up most frequently by both experts and “practitioners,” was “being present.”

We’re not talking, of course, about being literally, physically present (although that’s fairly essential), but about being mentally and emotionally there in your body, in the moment. Here’s how one woman who was interviewed for the study put it:

“The difference is when I can really just let go and completely focus and be in the moment and not have that, you know, running commentary going through my head about anything else.”

For women our age, that running commentary is likely to include not only the long to-do lists of our everyday lives (what am I going to fix for dinner? how can I convince Mom that she really does need that hearing aid? I hope Sally’s midterms aren’t stressing her out too much), but the new and nagging concerns that come with middle-age sex (does my face look more wrinkly when I’m on top? is he going to be able to keep his erection this time? I’ve really got to get back into a regular routine at the gym).

There’s plenty of evidence that the practice of mindfulness — non-judgmental, present-moment awareness — helps people manage things like stress and depression. It only makes sense that intensely focused attention, the ability to be fully aware of sensations experienced moment by moment, would be a central feature of sex at its best.

If you feel sometimes that you are not totally “there” during sex, that you’re distracted or just going through the motions, consider learning more about meditation and mindfulness. Being more present in all aspects of your life will help you more fully experience the pleasures and sensations your body is designed to feel.

Watch for more “components of great sex” in future posts, and let us know what you think. We’d love to hear what makes it “better than good” for you!

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Now that our new site has been up for a while, we’ve met and made friends with others in online communities serving midlife women and sharing information about sexual health. We’d love for you to meet some of our new friends:

The amazing women at Vibrant Nation invited me to participate in their — really very vibrant — community. It’s a great place to explore and share life with others our age. Four of our posts made the top 10 in August and September!

The folks at Best after 60 invited me to share some tips about encouraging sexual responsiveness as we age. That’s a great site to explore all sorts of “Bests” that come with experience.

Liz from Flashfree (Not Your Mamas Menopause) asked for a guest post on her blog, where she writes about the physical, emotional, and societal issues that surround midlife and menopause. I was happy to oblige.

I had a great time discussing sex at menopause on the Voice of the Nation show “Sex with Jaiya”, who was very interested in hearing about how we can adjust our ideas about sexuality to meet the changes we experience as we age.

Melinda Blau’s MotherU is a marvelous blog she keeps with her daughter, Jennifer Blau Martin. Melinda is a bestselling author, and a brilliant blogger who does a great job of including as many voices as she can on her comforting and informative blog. She asked to run our recent contemplation of new grandmotherhood.

And we love Owning Pink, an online community that endorses and celebrates living full and authentic lives. I’ve joined the Pink Posse to talk about Owning Sexuality. I swear it’s not just so that I can say that I’ve joined the Pink Posse, though that’s a pretty good reason to join up.

In the off-line community, we’ve just come back from participating at The North American Menopause Society Annual Meeting in Chicago and the Nurse Practitioners in Women’s Health Women’s HealthCare Conference in California. We made lots of new friends–and were exhilarated by the response! Whew! Now to catch our collective breath…

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There are many “natural” reasons women our age begin to lose interest in sex. Hormonal changes, diminished energy, lowered self-esteem as we mourn the loss of our youthful bodies — a complicated mix of physical, psychological, and social influences conspire to make us feel less sexy and less sexual.

When patients ask me about “natural” ways to increase levels of arousal and desire, my prescription almost always includes a combination of mindfulness and exercise. Awareness techniques like meditation help us focus on the moment and block out the stress and distractions of our everyday lives. Exercise increases blood flow, releases endorphins, tones our muscles and our perceptions of ourselves as strong and attractive.

I wasn’t surprised then, to read in a recent issue of the Journal of Sexual Medicine that yoga, a practice that combines both of these libido-enhancing elements, “improves several aspects of sexual functioning, including desire, arousal, orgasm, and overall satisfaction” — particularly among women over age 45.

This study, which surveyed healthy, sexually active women before and after a 12-week program of daily yoga practice, found significant improvements in all of the areas measured: desire, arousal, lubrication, orgasm, pain, and overall satisfaction. Nearly 75 percent of the women who participated in the study “said that they were more satisfied with their sexual life following the yoga training.”

Other research has found that yoga increases body awareness and can be used to direct blood flow to the pelvis to enhance arousal and lubrication. The mindfulness that yoga teaches and requires helps a woman be more aware of her body and its needs. “When you’re present, you know what you need to feel fulfilled by your partner,” explains one expert. “You can then translate and communicate this deeper understanding to your partner during sex.“

And of course the increased flexibility and improved muscle tone that come with regular yoga practice help a woman feel more confident and attractive — in bed and out.

If you’re looking for a natural way to tone up your libido, find a yoga class. And let us know how it works for you!

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There is no doubt that the ability to achieve an orgasm becomes more difficult as we age, and the orgasm itself is often briefer and less intense. As we age, we need more time for every step of the process, starting with foreplay. Sometimes our partners need to hear a clear message about what’s changing for us! We hope our website can make it easier to have those discussions with a partner.

Using a warming lube, like Oceanus G Stimulating or Sliquid Organics Stimulating O Gel, can improve sensation for some women. Warming lubes include a minty or peppery ingredient, which increases circulation and sensation in genital tissues.

You mention occasional orgasm success with a vibrator. Not all vibrators are alike: Some don’t provide the intensity of vibration that our tissues need in midlife. We offer vibrators by Emotional Bliss that are more powerful than average, designed for those who specifically need more stimulation, more intensity. I’ve seen some amazing results with these in women who previously were unable to have an orgasm because of neurologic diseases or medications that are known to interfere with orgasm.

You might also talk to your health care provider to see whether vaginal (or localized) estrogen is a good option for you. Lack of estrogen to vaginal tissues results in a decrease in circulation, which leads to less sensation, which is why you may not sense penetration as you did before.

Do talk to your partner and explore your options. Sexual satisfaction comes in many forms, but if you’re missing orgasms, there’s no reason to leave them behind.

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No, I’m afraid a moisturizer won’t help with bladder function. Moisturizers really only improve the tissue condition in the vagina where they’re applied.

The vagina and the base of the bladder and urethra do have some tissue characteristics in common–they have the same embryonic origin. They both, for example, have estrogen receptors. That means that localized estrogen in the vagina can influence bladder function like frequency and urgency. Estrogen for localized application comes in several forms, but moisturizers don’t contain estrogen.

If you are bothered by urinary urgency or frequency, I’d encourage you to see your medical practitioner; there can be multiple causes and there are solutions for each!

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Recently I treated a patient who’d had elective breast reduction surgery. Nerve damage during the procedure had caused her to lose all sensation in her nipples. She found herself unable to have an orgasm without the extra stimulation those nerves had provided. That was a consequence she hadn’t thought to ask about!

Changes in nipple sensation are possible side effects of any type of breast surgery, including elective surgery to increase or reduce breast size. Sometimes the effects are temporary, but they can be permanent. It’s important to understand these risks — and the role your breasts play in sexual arousal and satisfaction — when choosing breast surgery for cosmetic reasons. I don’t know if my patient would have made a different choice, but she may have.

How do breasts contribute to orgasm? Some women (not most) can reach orgasm through nipple stimulation alone. Others rely on intense breast and nipple fondling to “put them over the top” during oral sex or vaginal penetration.

Like the clitoris, nipples are bundles of nerve endings that respond to touch by releasing certain hormones in the brain. One of these hormones, oxytocin, is sometimes referred to as the “cuddle hormone”: It makes us feel warm and open toward the person whose touch initiated its release in our bodies. Other hormones, including testosterone and endorphins, combine to create a surge of sexual arousal that increases blood flow to the clitoris and stimulates vaginal lubrication.

For most women, sexual foreplay is essential to getting us interested in and ready for intercourse or penetration. And for most women (82 percent in one study) breast and nipple stimulation are an essential ingredient of foreplay.  We talk a lot about clitoral stimulation and vaginal maintenance for maintaining our sexual satisfaction, but other parts of our bodies also play a part in arousal and orgasm, though.

For those of us fortunate enough to retain the pleasant sensations our breasts can provide, remembering these important sites of arousal during foreplay and intercourse (warming and massage oils can work wonders here) will enhance our readiness for and enjoyment of sex — at any age. Let’s not forget to raise our focus — to our breasts.

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