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Archive for November, 2010

Critics of the quest for “pink viagra” — the elusive drug to increase female sex drive — often argue that depressed libido isn’t medical condition (like erectile dysfunction) that can be “fixed” with pharmaceuticals.

But a recent study by medical doctors at Wayne State University suggests that there may be measurable physiological differences between women who suffer from what researchers term “a distressing lack of sexual desire” and those who have a “normal” sex drive.

MRI scans of women viewing video clips that alternated between erotic scenes and nonsexual content found that areas of the brain that normally light up when thinking about sex remained dark in women with low sex drive, while other areas that usually don’t show activity lit up.

According to Wayne State’s Dr. Michael Diamond, who presented the findings at the annual meeting of the American Society for Reproductive Medicine last month, these brain pattern differences may provide the first “significant evidence” that, for some women, lack of sexual desire is a physiological disorder. One that could possibly be treated by meds — pink or otherwise.

Although the study sample was small, and researchers have yet to understand exactly how these different regions of the brain relate to sexual arousal and response, for me these findings support the need for further research in this area. And raise hope that there eventually may be a medical option for women suffering from chronically low levels of desire.

We may find that some women are just wired differently and can benefit from a drug that improves their interest in sex, the way some people with ADD benefit from drugs like Ritalin and Adderall that improve their level of focus and concentration. Of course, some ADD patients prefer not to use medication and are able to make other adjustments that allow them to function well in their daily lives. And, if we do develop a “pink viagra,” it won’t be the solution for every woman. I’ve found that pain-free sex and a communicative partner can do wonders for the libido.

But I’d love to see the day when taking a desire-enhancing medication is a choice that a woman can make for herself. And studies like this one and the further research it will inspire move us closer to that goal.

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Many of the women I see in my office would like a black and white answer: Where, exactly, are they on the path to menopause? Unfortunately, I can’t really give them a solid answer, and here’s why.

Perimenopause—that period (no pun intended!) between regular menstruation and menopause—isn’t a steady progression. It’s more like two steps forward, one step back. Sometimes, one step forward, two steps back. You may have some signs along the way, like moodiness, insomnia, irregular periods, hot flashes, lack of interest in sex, or vaginal dryness.

Sometimes FSH tests are used to help fill in the picture, providing one more data point. I don’t often recommend these tests, though, because although the tests are accurate at that moment on that day, they can be wildly misleading—unless you’re not yet in perimenopause (in which case the test can point to other issues) or you’re in menopause—which you already know because you’re not menstruating.

Here’s what’s happening with FSH (follicle stimulating hormone): The pituitary gland sends out FSH to tell the ovaries to make estrogen, which helps eggs grow (stimulating follicles!) and thickens the uterine lining. The pituitary gland acts like a thermostat: if it senses estrogen production is low, it “kicks on” and releases more FSH.

But as I said, the path to menopause is not a straight one; most women have erratic periods before menopause. So even if you are 52 and have every other symptom of perimenopause, if you take the test during the one time in six months you happened to ovulate, your FSH levels would suggest you’re not menopausal. Lifestyle-related factors like stress and smoking also affect FSH levels, making them even less helpful.

Check out the graphic to see the kind of unpredictability that’s typical. The first graph shows regular
Typical Hormone Fluctuationshormonal fluctuation whenyou’re having regular cycles. The second graph shows how wildly all four hormones may vary over six months. The last graph shows that a consistently high level of FSH accompanies menopause. But, again, if you’re not having periods, you don’t need a hormone test—either from a doctor or an at-home saliva test—to tell you you’re menopausal. (If, by the way, you’ve had a hysterectomy, endometrial ablation, or another procedure that’s eliminated periods but you still have ovaries, you have the same unpredictability in hormone levels. Charting your symptoms for a few months may be the most helpful approach.)

I understand that the ambiguity of perimenopause bothers some women. As a physician with a pretty good understanding of all the pieces at play, maybe I find it too easy to recommend that women tune in to their bodies and take it a month at a time. How have you found peace with the changes that are part of The Change?

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This Lube Is My Lube

When we were assembling our product collection, the MiddlesexMD team spent a fair amount of time researching personal lubricants. Some of this research was straightforward: We knew safety came first, of course. We knew glycerin is a nice ingredient for some women, but for others it encourages yeast infections. Some of us (in particular women who want the lube to last as long as 45 minutes without reapplying) like silicone-based lubes, but they don’t work for women who use silicone-based massagers or vibrators. For some of us a thicker gel is more comfortable; others find a slippery liquid to be just right.

We did our homework. We were thorough. We assembled a variety that covered these bases, as well as preferences for organic ingredients and sensitivities to others. And then, that poor product team: If you’ve looked at our product catalog, you know we try to give a little extra information, a bit about why we as women of a certain age like the products we offer, what to look out for, who might be especially interested. The product team felt obliged to provide some pointers on smell, feel, and, yes, taste—for each of the lubricants.

So the team devoted an afternoon to exploring the options. They learned a lot. There were one or two, for example, that everyone agreed they’d rather not taste again. There was one in particular that a majority thought smelled pretty good. One lube seemed to moisturize the skin really well. The truly important thing the team learned was that Diet Coke could “cleanse the palate” between lubes.

That experience testing lubes made us think. If we hadn’t had all the samples on hand, we never could have tried so many so quickly. Since none of the quality lubes is cheap, how does the average woman find the one she likes best? Without investing a fortune and struggling with her conscience about dumping the nearly full bottles she doesn’t like? Do women put up with one they don’t like—that doesn’t last or smell good or feel good or… er… taste good—because it’s too much of an investment to find a fave?

And that’s how we came up with the Personal Lubricant Selection Kit. We send you trial-size amounts of various types of lubricants and a card you can redeem for a full-size bottle of your favorite. Easy.

And you know what? That Kit has been one of our most popular products since we launched our store. It’s gotten a lot of attention at the conferences for health care providers we’ve been at lately. And we’ve gotten quite a few cards back from women who’ve conducted their own tests.

You might say all these women agree to disagree: There is no single favorite. There’s not even a trend. Not for which lubes feel best, not for which lubes smell best—not even for which lubes taste awful!

This is good news for us, of course: It means we really did have a useful idea when we put that Selection Kit together. And any day, I’m confident, the product testers will begin to forget that long afternoon with the Diet Coke chasers… and when they’ve forgotten, maybe I’ll tell them just how individual these preferences are—and how many taste tests they could have skipped.

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What’s the difference between “connection” (number two of the “eight components of optimal sexuality”) and “deep sexual and erotic intimacy” (number three)? That stumped me for a bit while I was digesting the study published last year in The Canadian Journal of Human Sexuality.

Then I read this quote from one of the study’s participants, describing a type of intimacy that goes beyond intense connection in the moment: “It’s part of the way you act with each other long before you’re actually engaged in any kind of, you know, technical sex.”

I like that. I think that “the way you act with each other” before, after, and during “technical sex” is essential to deep erotic and emotional intimacy. Trust, respect, and real admiration and acceptance build the foundation for a truly intimate relationship. These are things that take time, that come with knowing each other in a profound way.

And, in my experience, you can tell if a couple has this kind of intimacy just by observing the way they interact at the grocery store or a dinner party. Do they laugh at each other’s jokes? Do they exchange quick touches and knowing glances? Do they refrain from criticizing each others’ tastes in breakfast cereal?

According to study participants, a deep sense of caring for one’s partner is a key characteristic of sexual intimacy. One woman mentioned that her need to feel solicitude and concern had become more important to her with age: “I don’t know that I’m capable of having great sex anymore without really caring about a partner.”

The study’s authors noted that “almost every participant identified a deep and penetrating sense of trust as characteristic of the intimacy that was part of great sex for them.” They needed to trust that their partners cared for them and that the relationship was secure.

This kind of trust and intimacy doesn’t just happen. It takes time and openness and communication. Especially at midlife, when our bodies and needs are changing, it’s important for partners to talk with each other, to stay up-to-date on feelings and desires. Honest and caring talk about sex can be erotic in itself, and can go a long way toward creating and maintaining the deep intimacy that makes for sex that is “better than good.”

More on this next week, when we look at component number four: Extraordinary Communication!

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A vaginectomy–surgical removal of part or all of the vagina–is most often done as part of cancer treatment. It’s rarely a doctor’s first choice, and some reconstruction is usually involved. Your health care provider’s evaluation is an important first step.

If your health care provider believes there’s physical capacity for intercourse without further reconstruction, there’s more you can do to be sure that you’re comfortable. A regular routine with a vaginal moisturizer will help keep your vaginal tissues healthy and elastic. You may want to use a lubricant with penetration. Make sure that you’re giving yourself time (and attention!) to become fully aroused. Especially if you’re having sex again after some time alone, you may be in a rush!

If you’re still not comfortable, vaginal dilators may help. They can increase both the vaginal opening and the depth by gradually and gently stretching the tissue.

Keep working at it! Regaining your sex life is definitely worth some time and experimenting.

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Many of the women I see in my practice have been with the same partner for years. These couples have made homes together, raised children together, weathered hard times and enjoyed happy moments together. And now—just as the pressures of career and family begin to ease up, they find themselves at odds with each other, especially in the bedroom.

The physical and emotional changes that come with aging can play havoc with a couple’s sexual relationship. It can feel as if the rules have changed overnight and finding intimacy with the person who has shared your life is suddenly impossible. This is when a couples therapist can help.

Women who have never been in therapy or participated in marriage counseling before sometimes feel anxious when I propose this idea. To help give them and our readers an idea of how couples therapy works and what they can expect from the experience, I asked Ann McKnight, an experienced social worker and psychotherapist, to answer a few questions.

Q: When couples who have been together for a long time come to you with sexual issues, what’s typically going on?

A: One of the most important things in intimacy is to be present and see clearly this person who is in front of us, and to be ourselves as open and receptive as we can be. That’s what makes great sex. In the beginning stages of a relationship, we have all our walls down—it’s exciting, it’s new, and we feel so open and vulnerable. But then as we move on together in life we start to get those walls built up again.

Usually it’s our own fears that keep us from being present, from hearing or being heard by our partners. If our partners are unhappy with our sex life, we start thinking there’s something wrong with me, I’m aging, you’re not attracted to me anymore. But what’s going on for our partners may be something totally different. They likely have their own set of fears that we’ve never guessed at or heard at all because we’ve been so caught up in our own.

Q: So the stereotypical story of the middle-aged couple—she’s putting on weight and he’s looking at skinny 20-year-olds—isn’t one you often encounter?

A: I have to laugh, because in my experience, that is so not the case! Maybe those couples are going to different therapists, but I’m just not seeing them. Actually, as men age, they tend to have a greater desire for intimacy, to value their long-term relationships.

I think there’s just so much cultural downloading that women do, so many judgments about aging and what it means and our values around that. And I’m not entirely sure that that’s laid on us by men. I think that we do plenty of it to ourselves.

I think aging, because of life experience, gives us—women and men—an opportunity to be kinder and more understanding of ourselves. We can integrate more fully all the parts of who we are and all the different roles we play—open our hearts even more fully to each other, to really see our partners and all the change and growth they’ve done.

But in long-term relationships it can be hard for both partners to hold the space they need to express themselves and be seen. That’s when a therapist, a third person who can hold that space, who is trained to see where the communication is getting bogged down, where the stuck places are, can be a great help.

Q: What’s the best way to find a good couples therapist?

A: Ask someone you know and trust, whether that’s your physician, a friend, your pastor—and then when you do get a name, use the first time you meet to make sure it feels like a good fit. Does this seem like a person who is understanding each of you and proposing a course of therapy you’re both comfortable with? If not, get another name.

Q: And what if the other half of your couple resists the whole idea?

A: Still go. If there’s something going on in the relationship that’s affecting you, that’s part of your personal experience that you’re ultimately responsible for. And whenever one person starts to make changes in a relationship, things shift and get stirred up in the other person as well.

Q: How should a couple prepare for their first session?

A: As a couple—or individually—think about what you really are hoping will come out of this experience so that you can be open about that with your therapist. Sometimes what we really want is not very realistic—I want you to totally change my spouse’s behavior in every way! Just understanding your own agenda is a big help.

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We had a flurry of questions about foreplay — or dealing with the lack of it — awhile back, which led to a number of conversations within the MiddlesexMD team, but also between team members and their partners. This guest post — from a man! — was spurred by one of those conversations. We think it’s important — and reassuring — to hear that men do like foreplay. If this is a topic you’d like to raise with your partner, perhaps sharing this post is a way to do it. –Dr. Barb

“And the women crazy ’bout me ’cause I take my time.”
–Taj Mahal, “Little Red Hen”

I was 12 years old when I first heard about what goes on during foreplay. A mouthy teenage boy from across the street told me about it as he smoked a morning cigarette on his front porch. I really didn’t want to hear it, and when I did I couldn’t understand why anyone — man or woman — would want to do such things to each other. I was barely able to fathom what foreplay led to, and this just made the whole thing even more bizarre, at least to a kid living in the Midwest in the late 1950s.

I learned too many things about sex from other, usually older, boys. My parents stayed away from the subject, figuring, I guess, that I’d learn from other boys. So, much of what I learned was from their raging-hormone perspectives. The focus was always on them and their pleasures, their “conquests,” imaginary or not. I can’t remember hearing guys talk about sex (much less intimacy) from the girl’s point of view — sex was more, as we say now, all about them. I saw this attitude flourish in college in the late 60s, when guys practically competed for sexual supremacy, which you couldn’t achieve with just one partner. “Wham, bam, thank you, ma’am” relationships were fine and dandy. Numbers mattered.

Which brings me back to foreplay. It’s hard to say that it’s a lost art if it was never discovered in the first place. Or maybe, like so many things in relationships, it’s been allowed to languish, to become an afterthought in a hurry-up world, especially as we grow older. There are all kinds of reasons why foreplay might get shortchanged or forgotten. And it’s not as if it can just be wished back into existence. Mutually exciting foreplay depends on couples being willing to take an unhurried approach to their lovemaking, to find out what makes each person feel sexually energized and ready for more. In our haste to get to home base, we men tend to want to bypass first, second, and third. Women, seeing our haste, assume that that’s just the way it is — that men prefer sex with no prologue.

I’ve learned that if you miss the prologue, the play’s not nearly as good; you can’t drive a woman wild by rushing into the final act. But you can heighten her lust for you, and yours for her, if you learn to let the present moment linger for a while and enjoy it to its fullest. You’ll both know when it’s time to move on, and you’ll both be ready for it.

I think that words are a key part of foreplay. Words that precede any touch. Words that express your appreciation of her, your attraction to her. Words that ask her what she’d like you to do. Words that continue during foreplay and beyond, not a lot of them but occasional affirmations, expressions of desire, words that keep you connected both physically and, well, orally.

Everybody is happier and more satisfied when foreplay is part of the experience. It’s something that makes both men and women want to have more of where that came from. Who can argue against such self-perpetuating pleasure?

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It’s interesting to me how many patients who come to me with concerns about diminishing libido are there because of their husbands or long-time partners. These lucky women have a great relationship with a great person, and they don’t want anything, including their own lack of sexual desire, to jeopardize it.

I respect that. I think that the desire to keep a long and satisfying relationship intact is a good reason to want to want to have sex.

I also believe that a lot of women in this situation sell themselves short. They think that because their partners want to have sex more often than they do themselves, there is something “wrong” that they need to “fix.” Often, it’s just a matter of timing.

Being “in the mood” for sex comes more easily to men. A man who is physically healthy and capable of an erection is almost always in the mood. Men are wired to go from zero to sixty on nothing more than a flash of leg or a lingering kiss. Women, on the other hand, tend to rely more on emotional or intellectual stimuli to reach a state of physical desire. And that takes time.

My advice? Get out your trusty planner and schedule a date for sex. Think of it as extended foreplay. If you schedule a week in advance, you’ll have days to think about your date night–what you’ll wear, what he might say about what you’ll wear, how he will want to take whatever you’ll wear off you. You’ll have time to buy some candles, choose a new aromatic massage oil.

Most importantly, because you’ll have to synch your calendar with your lover’s, you’ll have time to anticipate and talk about sex with each other, to make the crucial emotional and intellectual connection that helps both of you get in the mood for physical intimacy.

Some people dismiss scheduled sex as unromantic or think that deep physical attraction has to be “spontaneous.” I think it’s important to distinguish between sex that happens spontaneously (which can be very nice!) and sex that includes creativity and spontaneity in the act of making love (also very nice!). Think of scheduling sex as a way of insuring that you and your partner have a space and time where spontaneous acts of love and erotic play can occur.

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Vaginal dilators really do work to increase vaginal caliber–the size of the opening. If you’re having your first sexual encounters, have an exam by your healthcare provider to rule out other causes: there may be an issue with the hymen, for example, that would have a different solution.

But for women who’ve been sexually active, dilators can make a world of difference. I had an e-mail a couple of weeks ago from a woman who hadn’t been able to have intercourse for two years. After using vaginal dilators for a month, she was able to have pain-free sex!

Dilators come in graduated sizes; the smallest is only a half-inch in diameter. They are used with a lubricant daily. When you’re comfortable with one size, you progress to the next-larger dilator until you’ve achieved the caliber–the opening size–that works for you and your partner.

Vaginal caliber is only one element of our sexuality, of course. I encourage women to think about the whole picture. But if a narrowing vagina is a problem for you, vaginal dilators really can help.

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We’re learning. I was happy to see that confirmed by Indiana University’s Center for Sexual Health Promotion’s findings in the latest National Survey of Sexual Health and Behavior.

I was glad to see that more Americans of all ages report they are engaging in a variety of sexual acts in addition to — or instead of — vaginal intercourse. Compared to the last survey, in 1994, more people are masturbating (alone or with a partner), giving or receiving oral sex, and generally experimenting with a medley of different sex acts: 41, to be exact.

And that doesn’t even include the use of sexual aids like vibrators.

This is good news for everyone, but especially for women — and especially for women of a certain age. As this latest study confirms, women are less likely then men to experience orgasm during vaginal intercourse without additional stimulation. And as we get older it takes often takes additional additional stimulation to get the kind of sexual release we got used to enjoying in our 20s and 30s.

Feeling free — and knowing how — to mix it up, to combine several ways of making love in a single sexual encounter, makes it easier for women and the partners who love them to experience the full range of intimate pleasure.

The National Survey of Sexual Health and Behavior found that women were more likely have an orgasm if their partners used more than one technique in bed. Fifty-four percent of women who had “one-act” sex during their last encounter reported having an orgasm, while 89 percent of women who included five sex acts in their most recent assignation enjoyed orgasm.

Another piece of good news from the study: among women 50 and older, solo masturbation was more commonly reported than most other sexual behaviors. To me, this suggests that masturbation is not only less taboo among older women that it once was, it also indicates that more women are actively maintaining their bodies for sexual enjoyment. As a doctor who specializes in the health of women over 40, I’m a strong advocate of self-stimulation. It helps us remain sexually healthy and responsive (not to mention in a good mood) during times when we are without partners. When we have partners, it can help prepare genital tissues for comfortable intercourse and/or orgasm.

You may not aspire to all 41 acts. But if you’d like to expand your sexual repertoire, our website offers information and products that can help you expand your knowledge and pleasure. Branch out!

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