Archive for July, 2011

Okay, so you’ve tried everything. You regularly use a good, natural moisturizer, plus a lubricant during sex. No soaps, sprays, scents, dyes, or synthetic underwear ever touch your bottom. You’re the queen of vaginal hygiene. And still you’re troubled by dry, itching, or inflamed genitals and painful penetration.

What now?

Talk to your doctor about using a localized estrogen product for your vagina. These medicines deliver low dosages of estrogen right where it’s needed: the vagina and vulva. Not only is localized estrogen medication very effective at relieving the discomfort of vaginal inflammation or atrophy, but it also restores natural vaginal lubrication and elasticity. In fact, while it won’t relieve other menopausal symptoms—like hot flashes—low-dosage vaginal estrogen is sometimes more effective in relieving menopausal genital problems than systemic hormone replacement therapies (HRT). Moreover, the dosages are so low, the side effects and complications so negligible, it is often used by breast cancer survivors.

Vaginal estrogen comes in several forms: a cream (used twice a week), or slow-release tablets (used twice a week), or a ring (which needs to be replaced every three months). Don’t, however, confuse the Estring vaginal ring with Femring, which is the high-dosage HRT in a vaginal ring form. (Confusing? It can be.) Your doctor will tailor the amount and frequency of application for the maximum effect at the lowest possible dose. It may also take several weeks for treatment to become fully effective.

A few precautions:

  • Avoid applying your estrogen cream right before intercourse, since your partner can absorb it through his penis. Estrogen rings and tablets are meant to stay in place and don’t have this effect.
  • Continue to use non-hormonal lubricants and moisturizers if necessary.
  • Have regular vaginal intercourse to augment natural lubrication and a healthy vagina.

While localized estrogen may not be the first line of defense against the unpleasant genital changes related to menopause, it’s an important option when simpler methods (like vaginal lubricants or moisturizers) fail.

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Dilators are not intended to fit all the way inside your vagina. The extra length gives you some space to hold on to and to apply gentle upward pressure. The pressure gently stretches the tissues to achieve additional length or depth in your vagina.

The graduated diameters of the dilators in the set are intended to address narrowing of the vagina. Use the smallest one until it’s comfortable, and then move to the next-larger size. We offer a more complete description of how to use dilators on our website.

I also encourage the consideration of vaginal moisturizers and localized estrogen to help keep the tissues healthier and more supple. That in combination with the dilators can give you more comfortable, faster, more lasting results.

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As a medical doctor, I try to provide a place where uncomfortable or unfamiliar topics can be discussed in an open, honest way, without inhibitions or worries about “what people might think.” For lots of people, both men and women, self-stimulation or masturbation falls into that “uncomfortable” category. Some of the myths surrounding masturbation—like it causing blindness or hair to grow on the practitioner’s hands—have faded, thank heavens! But there’s still a lingering perception, I find, that self-stimulation is somehow less acceptable for women than for men.

For post-menopausal women, self-stimulation is especially helpful, whether or not they have partners. It can solve problems with vaginal dryness or tightness: Stimulation causes your clitoris to swell, helping to maintain healthy blood flow to the walls of the vagina, which in turn can help keep your vagina open, strong and responsive. (It’s the old “use or it lose it” rule.)

If vaginal dryness or tightness is a problem, self-stimulation can also be a way to temporarily feel sexually satiated if intercourse is too painful. I say “temporarily” because I don’t recommend that you think of it as the solution to painful intercourse. Always seek medical attention if you’re experiencing any kind of vaginal pain, because there are lots of remedies.

Another benefit of stimulating yourself is the way it helps you to get to know your own body and what satisfies you best. As hormone levels decrease and effect other changes in your body, what’s worked in the past may not be as satisfying now. It’s great to be able to experiment with your partner to find your new best experience, but that’s not always possible, for all kinds of complicated reasons. Old habits die hard, and either you or your partner may feel tense or intimidated about changing things up. You can experiment to see what works for you and then share that knowledge with your partner to make your sex lives more mutually satisfying.

If you don’t currently have a sex partner, self-stimulation is a great way to enjoy the side benefits of sex, like tension and stress release and the feeling of calm and relaxation that immediately follows a sexual session. Fantasy can be a fun part of it; picture yourself with a former lover—or George Clooney (or Dean Martin… or… you tell us!). And taking care of yourself in this way keeps open the possibilities in case you do find yourself in a relationship again. In my decades of practice, I’ve learned never to say never!

If your sex life is suffering from other issues—a rough time in your relationship or it seems to hard to get your love life back on the right track—I caution patients against replacing intimacy with a partner with self-stimulation. It may be the “easy” thing to do, but it can compound problems if you turn to self-stimulation instead of your partner for satisfaction.

Self-stimulation is a normal part of a healthy sex life. At this point in our lives, the last person we need to be shy with is ourselves. Who knows what we’ll learn?

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Sex on the Brain

We’ve talked before about mindfulness – making a conscious effort to become more fully aware of something and thinking more deeply about it – and how being more mindful of sex can help increase your desire for it.

Because like many things in our busy lives, it’s easy to put sex on the back burner, along with items like haircuts and ironing. And if that burner’s not turned on, things can cool down pretty quickly.

And let’s face it, as we get older, our sex drive can diminish as hormone levels drop after entering menopause. So unlike when we were young and our hormones were raging, sex isn’t always “on the brain,” as it used to be. And unless you’re pro-active about putting it there, it might go away. Which would not be a good thing because sex and intimacy are such important parts of a well-balanced, healthy relationship.

But once you make the decision to become more mindful about sex, you’ll find many opportunities to incorporate sexual thoughts into your life. And it starts in places other than the bedroom.

Like the kitchen, for example. There’s always been a great relationship between food and sensuality (remember the movie Tom Jones?). You might want to check out The New InterCourses: An Aphrodisiac Cookbook on our website. It explores the history of aphrodisiacs and offers a guide for pairing dishes with relationship stages and different times of year. It also includes easy recipes for massage and bath oils. Why not give it a try? It might just lead to a romantic encounter.

Speaking of baths, next time you’re in the tub, put out some candles and invite your mate to come in and chat while you soak. It’s a peaceful and relaxing setting (no phones allowed) that’s ideal for conversations about intimate topics like… your sex life!

Remember, too, that we women are much more responsive when we’ve received sexual stimuli — thoughts, sights, smells, and sounds — than we are to just diving into sex spontaneously. Getting in the mood might just be a matter of giving some thought to what turns you on – and telling your mate about it.

As the old saying goes, “Sex starts between the ears,” and that means in your head. So if you want to keep your sex life active – or get it cooking again – start thinking about it more. And watch what happens.

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Orgasm. Such a complicated topic; so many questions, so few answers. But let’s focus on the most important point, which is, that for women, the biggest obstacle to experiencing orgasm is anxiety. How can anyone relax while having sex if she’s thinking, “Will it happen this time or won’t it?”

As you can imagine, research on this topic is somewhat limited. But the renowned sex researchers William Masters and Virginia Johnson, who were the first to describe the four-step process of experiencing orgasm (during intercourse) many decades ago, said there are four steps involved:

1) Excitement. During foreplay, blood begins to engorge the clitoris, vagina, and nipples, and creates a full body sexual blush. Heart rate and blood pressure increase.

2) Plateau. Sexual tension builds as a precursor to orgasm. The outer one-third of the vagina becomes particularly engorged with blood, creating what’s called “the orgasmic platform.”  Heart rate, blood pressure, and respiration continue to increase.

3) Orgasm. A series of rhythmic contractions occur in the uterus, vagina, and the pelvic floor muscles. Sexual tension releases, and muscles throughout the body may contract. A feeling of warmth usually emanates from the pelvis and spreads throughout the entire body.

4) Resolution. The body relaxes, with blood flowing away from the engorged sexual organs. Heart rate, blood pressure, and respiration return to normal.

(For another model of sexual arousal, remember Rosemary Basson‘s, which takes into account women’s more complicated reality.)

Another good thing to know is that experiencing orgasm during intercourse takes time. In one study of 1,000 women, the “mean duration” was about 13 minutes. So trying to hurry it along or time it to coincide with your partner’s is probably not going to help.

It all gets back to the whole idea of relaxing—of letting go and focusing on the moment, enjoying the closeness and intimacy itself without worrying about what the outcome will be every time you have sex.

And, too, most women—two thirds of us—never experience orgasm at all during intercourse; some say the only way they ever get there it is through hand stimulation (their own or their partner’s) or with a vibrator, which often is the quickest route.

If you’re having trouble experiencing orgasm, try some things on your own to see what works and what doesn’t, not just physically, but mentally. Some women, for example, find that fantasizing puts them in a “zone” where they can escape the distractions of life. (Imagine yourself on a desert island with the one you love!)

This is one of those things that can only get better with honest, open communication. Talk with your partner about your feelings, your reactions—everything—so that you both have a good understanding of what’s going on and why.

Let us know your questions about experiencing orgasm; we’ll do our best to answer them (if you’d rather not post them here, use the “Ask Dr. Barb” button on our site). And in the meantime, relax and enjoy the journey.

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Sex and religion aren’t often mentioned in the same breath. One is fleshly; the other spiritual, right? Like oil and water.

Yet, both are integral to our person and to our psyche. Both faith and sexuality are deep expressions of who we are. We can’t chuck our sexuality at the door of the church or temple or synagogue; nor can we drop whatever we believe about God at the door of the bedroom.

So I was interested to read about a recent survey conducted by psychologist Darrel Ray, who compared the behavior and feeling of nonbelievers (agnostics and atheists) to those of believers (mostly of Christian persuasions). In a nutshell, he found that both groups behave similarly. Both became sexually active at about the same age, have similar levels of sexual activity, do the same things in the bedroom. They even pursue affairs at similar levels. The significant difference was that the believers tended to feel more guilty. This was particularly pronounced in more fundamental denominations: Mormons, Jehovah’s Witnesses, Seventh Day Adventists, Pentecostals, and Baptists. But mainline Protestants and Catholics experienced higher levels of guilt, too, than atheists or agnostics. Not crippling, but noticeable.

Leaving aside for a moment serious questions about Dr. Ray’s motive and methodology (he calls religion a disease and himself a “recovering religionist”), his report raises some interesting questions. Do people who believe in God feel guilty about sex? Are certain acts, masturbation or oral sex, for example, more troubling or guilt-provoking? If so, why would this be? Does guilt derive from actual church teaching or from cultural conditioning or from something misunderstood or misapplied in childhood?

Even the religious institutions themselves struggle to honestly incorporate sex in a faith context. Yes, sex, in the context of a loving, uncoerced relationship, is a beautiful, God-given gift. Just read the Biblical Songs of Songs. However, as it’s practiced on the ground, the message isn’t all that clear, and even some church leaders admit as much.

“In the context of Catholic teaching, I would think it safe to say that the connection [between faith and sexuality] is contorted, controverted, and often confusing,” says Dr. Michael Higgins, vice-president of Mission and Catholic identity at Sacred Heart University in Fairfield, Connecticut.

“If we could only transcend the ‘forbidden fruit’ mindset, perhaps religion could evolve into a much healthier sexual ethic,” said Rabbi Howard Voss-Altman, of the Reformed Jewish tradition.

Dr. Sheema Khan, a practicing Muslim, said that “…sexuality forms part and parcel of [Muslim] spirituality. There are even prayers prior to sexual intercourse, and… foreplay is encouraged (as part of religious teachings).” But she also condemned the Muslim preoccupation with the “purity of women,” which could result in the ritual killing of a woman suspected of having sex outside of marriage.

So it would seem that if we aren’t sure how to feel about sex or some sexual behaviors, or if some indefinite guilt is associated with sex, we aren’t alone. Our religious institutions are grappling with the same issues.

But isn’t this the nature of life—to honestly articulate and wrestle with our inconsistencies? And in the end, to become more mature and integrated?

I remember the advice a wise old pastor gave my mother when she was trying to reconcile church teaching with the expression of sex in her marriage. “I don’t think that anything a loving couple does in the bedroom to give each other pleasure can possibly be sinful,” said this man of God.

Amen to that.

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In past posts we tried to identify books and movies that we thought were hot—the kind of stuff to turn on a more discriminating, mature woman. It wasn’t easy. In the normal course of things, women are simply not turned on by straight-up porn. And sometimes, even if a woman is physically aroused, she can be mentally repulsed.

Experts agree: the arousal/desire circuitry in a woman is complicated.

For men, it’s simple. A two-minute video clip, a sexy photo of a favorite star, a crotch shot, and he’s off to the races. “Give a guy an erection and he basically wants to use it,” writes sex counselor Dr. Ian Kerner, columnist for CNN. “In men, porn initiates the ‘sexual-circuit’ very quickly.”

Guys tend to view porn by themselves; their comments on online sites tend to be monosyllabic: “Hot!” Often, their porn consumption is unpremeditated—they might see a racy photo, and they search for more stimulation, basically to “get it on.” And virtually all men consume porn. In an effort to understand the impact of porn on men, a researcher from the University of Montreal looked for a sample of young men who had never viewed porn. According to Kerner, he couldn’t find any.

By contrast, the process for women, according to the co-authors of A Billion Wicked Thoughts: What the World’s Largest Experiment Reveals About Human Desire, “are not explicit scenes of sexual activity but character-driven stories of romantic relationships.”

Neuroscientists Ogi Olgas and Sai Gaddam screened the enormous amount of data available on the Web to analyze who goes where and views what. Unsurprisingly, they found that only 1 in 50 subscribers to major porn sites were women. “In fact, the main billing company for porn sites flags female names as potential fraud, since so many of these charges result in an angry wife or mother demanding a refund for the misuse of her card,” writes Olgas.

The female version of porn, according to Olgas and Gaddam, are “fan fiction” sites that peddle racy romance novels. Literally millions of women across the globe visit these sites to read and discuss the stories. The most popular of these is FanFiction.net. Discussion boards and comments on the novels are often long and probing, examining character and plot—it’s very much a group experience. Women can also be turned on by sexual scenes outside their own orientation—women having sex, for example, whereas straight men tend to stick with the flavor they like.

The times may be a-changin’, however, as women find their own voice in this formerly men’s world. We wrote about the new, couples-oriented porn format on the Playboy channel. There are also porn sites for women, and even a Feminist Porn award. And women seem to be seeking them out for the same reasons men do—to “get in the mood,” for pleasure, to learn new tricks.

For a girlfriend guide to the world of erotica for women, check out sex therapist Violet Blue’s The Smart Girl’s Guide to PornYou could also check out the queen of literati porn, Rachel Kramer Bussel, for her popular anthologies of sexy writing as well as her own four-alarm work. Happy hunting!

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Seeing Red

Squeezies. The year was 1986, maybe. Or 1987. I’m not exactly sure, and precision is not important to this story. It matters only that it was the last day of the year. My sister and I were young, married, without our husbands, working hard, very tired, and feeling a little bit entitled to a good time, or as good as we could have without regrets.

I was visiting her in the college town where her husband was pursuing his graduate degree and where she was working a horrible job to keep them in their crappy apartment. He was off visiting family. And the apartment just wasn’t festive enough for a new year’s celebration.

We were confused about what to do. We didn’t want to foist ourselves onto other couples our age, bent on a romantic evening. We didn’t belong in a gang of single people, either. But we were so young, and wanted to feel pretty and desirable and giddy and all those things women of any age like to feel.

Precisely speaking, we wanted men to read our wedding bands and weep.

We had a standing joke all through those years when we were becoming less and less sure of our appeal. One of us would call, and the other would respond:

Caller: “Well it’s not as if I couldn’t get laid by another man if I wanted to.”

Resp: “Of course you could.”

Caller: “I mean, I’ve still got it.”

Resp: “Alway did. Always will.”

Caller: “For instance, I could walk into that truck stop there, right now, and I bet someone would do me.”

Resp: “Absolutely. And it wouldn’t cost you that much either.”

Caller: “Not too much.”

And then we would laugh and wonder, really, would it cost so very much? But we were very good girls. Fidelity always mattered to us. But we wondered…

I mentioned my sister’s terrible job. I think it’s a job no longer held by anyone, actually. She was laying out ads in that city’s big daily newspaper. It was a transient’s job and one of her transient co-workers had shared her method for getting all the sexual attention a girl could ever want.

It seems beauty had nothing to do with it. What a woman needed to do was exude sexual power. And the way to do that, she said, is this: You walk into a room. You pause. You squeeze your vaginal muscles, very hard. And you think, “Red.”

That’s it.

That is, you envision that color. A vivid red. The color of blood, of passion. Bring it into your mind. Fill your awareness with Red. All while squeezing. Hard.


That New Year’s evening, armed with this information, our plan was clear. We would head downtown, find a hopping bar or club. Upscale. Nice. Walk in. Squeeze. Red.

Did I mention that we were in Virginia? Yes, well, that detail does matter. So when I say that a soft little puffy bit of snow had begun to fall as we left her little apartment, you have the right sort of unease taking root in your gut.

Virginia just does not do snow. We sisters are from northern Michigan, where an inch of snow means nothing. Two inches may bring a comment. But we need four to six inches at a single drop before we begin to wonder about the state of the roads. Virginia falls apart at the first flake. A half an inch will have Virginians filling their bathtubs with water, seeking out candles and flashlights.

And apparently that’s just what all the Virginians in this town were doing as we hit downtown, looking for a party, our hot-roller-set hair lacquered up, wearing our Calvin Klein jeans and high heels.

We were aware that there was very little traffic. Well, none. Anywhere. We noted that many restaurants, bars, and clubs were closed. But our heads were just too full of our plans and our youth to connect the dots, it seems.

We stopped for cigarettes, I remember, at a 7-11, where the counter lady said she hoped we would get home safely. That didn’t really register with us, though. On we went until we finally found an open bar. Cash and cigarettes in our cute little purses, we parked and slogged through slush into the bar.


Three steps in, we stopped for a half beat…

That moment wasn’t quite long enough to register that there were only three people in the place, two of them customers who were clearly the profit base for the bar — old, colorless men in colorless clothes sitting very still, drinking intently, not looking around, but straight ahead into their pasts.

We squeezed hard enough to wobble on our heels. We filled the bar with a steamy red awareness. And then…

Well, I seem to remember that I started things by snorting, and then choking, and maybe a little spittle landed on my sister’s chin. My sister’s runny nose released in that moment, and we both fell against one another and into empty chairs, unable to breathe for several long minutes while we laughed until tears rolled and mucus spewed and spit flew from our various orifices.

The men, indeed, all turned to stare. The bartender looking as if he wouldn’t serve us anyway, said the bar would be closing early because of the storm.

“Uh, what storm?” we wondered. And that sealed the deal. We would have to go.

Deflated, dragging our fingers through our wet, sticky curls, we slipped and slid back to our cars, realizing, finally, that this town had no plows. No salt. No infrastructure for snow. And home was all uphill.

Squeezies. Almost 30 years later, squeezies (Kegel exercises now) are no longer just an option for women our age. We do them to keep continent, to maintain the muscles that let us enjoy orgasms, to keep organs in their rightful places. No longer a scheme for attention-getting, we do them in check-out lines, at traffic lights, waiting for trains, for kids, for grandchildren.

But I can never do my squeezies without a smile. Or Seeing Red. Or remembering hot rollers and high heels and laughing until the snot ran free.

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Bladder Matters

Every now and then, a question from a patient or website visitor tells me that bladder function is interfering with a woman’s sexuality. Maybe their “urge to go” makes them lose focus during an intimate moment, or maybe symptoms are making them feel less than sexy.

In addition to being located in a very neighborly way, the base of the bladder and urethra and the vagina also have the same embryonic origin. They both have estrogen receptors, which means that they’re both affected by changes in hormone levels. And sometimes, I know, when you experience discomfort, it can be a little hard to pinpoint exactly what’s happening where “down there.”

So let’s review a couple of common problems.

Twenty to thirty percent of us will have a bladder infection at some point in our lives. That’s the most common form of urinary tract infection (UTI), which also includes the kidneys and urethra.

A bladder infection is often the result of bacteria that has made its way into the organ, usually from the vagina or anus—again, that neighborliness. (Remember to wipe from front to back.) Symptoms include:

  • Pain or burning during urination
  • Urgent need to urinate immediately
  • Need to urinate extremely frequently
  • Passage of small amounts of urine at a time
  • Pain in the abdomen or lower back
  • Need to get up from sleep to urinate
  • Cloudy, bloody or bad-smelling urine

If you are experiencing any of these symptoms, see your doctor right away. A bladder infection is easily treatable with medication, but you’ll also want to make sure it’s not a sign of something more serious, like vulvovaginal atrophy or kidney problems.

Overactive bladder (OAB) occurs when the muscles of the bladder involuntarily contract, making the urge to urinate more frequent than normal. There’s a dry and wet version: If you can make it to the bathroom in time, that’s dry (or stress incontinence); if you have any leakage, that’s wet (or urge incontinence).

Watch your weight to make OAB less likely to occur; being in the top third of body mass index range increases your risk. You can also take these steps to eliminate or prevent OAB:

  • Do Kegel exercises, which, because of that neighborliness, are good for both urination and sex!
  • Limit your fluid intake before bedtime
  • Go to the bathroom twice before bedtime
  • Avoid caffeine, alcohol, citrus juices, and carbonated beverages
  • Avoid spicy and acidic foods

Other urinary problems, including incontinence, are not uncommon in post-menopausal women and are often a result of declining muscle tone in the pelvic floor—again, that estrogen effect.  Kegel exercises can help keep our organs in place and functioning well; localized estrogen may also be something you want to consider. But if you’re experiencing any kind of bladder issues, be sure to talk with your doctor about it. Just because these conditions are predicted for our age group doesn’t mean you have to put up with them.

Paying attention to your body is the first step to good health, but don’t neglect the second: Seeking help when something’s not right.

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A wonderful and unexpected benefit of starting MiddlesexMD has been meeting other women and men who are like-minded, who see the value in—have a passion for—supporting sexuality throughout our lives. As we’ve gone to conferences and association events, I’ve been able to talk to doctors, nurse practitioners, and therapists who are eager to spread the word and join forces.

I’ve talked before about how the mind is as important for women as the body; that’s what makes the Basson model of female sexual response so helpful for my conversations with patients. Our need to address the emotional as well as physical aspects of sexuality made one of our encounters especially fortuitous: We met Mary Jo Rapini, a Texas-based psychotherapist who specializes in intimacy, sex, and relationships.

As a psychotherapist, Mary Jo can help us to round out the resources we offer you—so we’re thrilled that she’s offered her expertise to MiddlesexMD! Mary Jo has a private practice, but also publishes and speaks in a variety of places; you’ll learn more over the next several months. Plus we’ll interview her from time to time on topics of particular interest to us as midlife women.

To give you an idea of what’s in store, here is an excerpt from Mary Jo’s recent post, “Women Need Time to Get Their Sexy On,” in YourTango (read the whole article online):

“Body image is so highly correlated with women’s sexuality that in a recent study reported in the Journal of Sex Research, Dr. Patricia Barthalow Koch PhD discovered that body image was one of the top reasons women don’t want to have sex. Men may have difficulty understanding this because many of them tell their wives every day how beautiful she looks only to realize their wife still doesn’t want to have sex. The husbands may not understand that although their intentions are good, their wife doesn’t derive her body image by what he says. It may help and reassure his wife, but more helpful is if she believes that she is beautiful and desirable. In other words, if she beats herself up, or is critical in regards to her looks when she compares herself to others no matter what her husband tells her, it falls on deaf ears.”

Yes! Precisely. I hear evidence of this same issue. And remember our discussions of erotica? How it’s different for us than for men? Mary Jo goes on to talk about the same issues:

“Women need different stimuli to turn them on than men. We don’t get excited when we see a naked man. In fact, most women prefer a man with shorts on to a man in the buff…. Your sex text may not do it for us, but if we catch a glance at your jaw while you are drinking from a water fountain in the right lighting, we may feel a sexual impulse. Women don’t talk to you about this, because we know you won’t understand. Women are also somewhat reticent about telling you what turns them on, because it is so different than what turns men on, or what media believes should turn them on.”

You can see why I’m glad to have Mary Jo’s perspective and expertise with us for our exploration. Watch the blog and our Facebook page for more results of our work together. We can’t wait!

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