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Archive for December, 2011

I posed this question to Mary Jo Rapini, an advisor to MiddlesexMD and a therapist, writer, and speaker. Here’s her advice:

You’re not alone in your feelings of being married to a man who cannot express his love. I am happy that you are healthy enough to advocate for yourself and your own sexual and emotional needs. There are several things I can suggest that may really help you feel more connected to your husband—and will help you feel better as well.

The SmartMarriages website has good information that can help you and your husband. They are very pro marriage, but more than that, they are pro relationship. Anyone who wants to improve her relationship could benefit from their resources.

Buy a book called The Five Love Languages, by Gary Chapman. Many couples have found it helpful; men like it, too, and reading it together will lead to better understanding of each other and how you each feel most loved. The author also offers weekend classes throughout the U.S.; you might find him in your area.

You and your husband would benefit from attending a marital retreat. If he doesn’t like groups, or if you don’t, I would suggest a private therapist. I think your husband would feel less threatened if you sought out a male therapist.

One of the most beneficial experiences to help couples become more emotional in their loving and more connected is attending Tantric classes, offered in many cities. They are a bit unusual, and some guys (especially older) are reluctant to attend, but if you can persuade him to go to just one, he will enjoy it.

Remember that men are raised to be competitive. They usually open up to their wives, but fear being “too vulnerable.” This may generalize to their sexuality. Try more touching with him and less talking or trying to “process emotions.”

Make sure you’re taking care of yourself, including having someone you can talk to! You need emotional support so you can regain your strength and confidence.

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Couples at Midlife

Until recently, no one has given much thought to the sex life and relationship satisfaction of middle-aged couples in long-term relationships. You know, ordinary people. So no one knows what keeps long-term couples happy together and happy in bed together.

Recently, however, the Kinsey Institute conducted an international survey of 1,000 couples from the U.S., Germany, Spain, Brazil, and Japan. The median age for men was 55 and for women, 52. The average couple in the study had been together for 25 years. Sound familiar?

In this first study of its kind exploring the “sexual and relationship parameters of middle-aged and older couples in committed relationships,” the Kinsey Institute wanted to identify qualities that contributed to the sexual satisfaction and relational happiness of these couples.

Some of the researchers’ findings were unremarkable, but others surprised even the researchers.

In this survey, respondents and their spouses answered questions about their health, sexual history, how often they kissed and cuddled, how often they had sex, and how often they felt arousal or desire, along with a bunch of other intimate details about their lives and relationships. The researchers focused on physical intimacy, sexual functioning, and how long the couple had been together as qualities that would be particularly predictive of sexual and relationship satisfaction.

They hypothesized that there would be few differences between men and women, but that women would tend to have less satisfying sexual relationships and that physical intimacy would be more important to them.

They weren’t as accurate as one might think.

First, duration—the length of time couples were together—did indeed contribute significantly to relationship satisfaction for both men and women, but in different ways. For men the connection between relationship happiness and its duration was linear—the longer the relationship, the greater the satisfaction.

For women, on the other hand, relationship satisfaction decreased until year 15, and then it steadily increased from year 20 on. Researchers hypothesize that this effect was due to the stressors of the childbearing years, and that once those years are past, “this change, along with the freedom from reproductive worries, may facilitate greater levels of sexual satisfaction…”

A surprising outcome was that men who cuddled and kissed more were also happier in their relationships. Physical intimacy was a more important predictor of relational satisfaction for men than for women. No such straightforward effect was found for women. Duration of the relationship and sexual functioning was more closely linked to relationship satisfaction than was all that kissing and cuddling.

This effect came as a surprise. “The degree to which physical intimacy (that was not necessarily sexual) was rated as important to men’s but not women’s relationship happiness was striking,” write the researchers, “suggesting a need for reconsideration of the role of physical affection and its meanings for each gender in longer term relationships.”

However, women were happier with their sex lives when the relationship included lots of physical intimacy. So although physical intimacy was linked to sexual satisfaction for women, it wasn’t so closely linked to relationship satisfaction, which suggested to the researchers that the two qualities operate somewhat independently.

For example, people who were satisfied with their sexual relationships also tended to be satisfied with their relationship (and this tendency was particularly marked in women who had been married over 30 years), but conversely, happiness in the relationship didn’t necessarily translate to sexual satisfaction.

Sexual functioning was important to both genders, but it was actually more important to women. Women who reported high levels of sexual functioning were significantly more satisfied with both the sex and with their relationships.

Overall, the report concludes, “women reported significantly more sexual satisfaction than men and men more relationship happiness than women, contrary to our hypothesis.”

So, ladies, it ain’t over til it’s over for any of us. Sex remains more important than ever as we get older, and it significantly impacts the quality of our lives. Sexual satisfaction contributes to the stability of our relationships, and if we can remain physically intimate and sexually active, we’re more likely to be happy with our sexual relationships as well.

These results have important repercussions for the choices we make at this time of life when we can no longer take our sexual apparatus, or our health, for granted. All our physical parts just take more attention and maintenance, but keeping our bodies and our sexual organs in good working order is absolutely critical to our quality of life—and to the quality of our relationships. And that’s the takeaway from the Kinsey research.

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Suzanne Somers touts them in her bestselling book, Ageless: The Naked Truth about Bioidentical Hormones. Oprah promotes their use. On the other hand, the Harvard Medical School, the North American Menopause Society, and the Endocrine Society take a more cautionary position toward compounded bioidentical hormones. And I find that many of my patients are just confused.

So what are bioidentical hormones and what’s all the controversy surrounding them?

We’ve written a lot on Middlesexmd.com about the importance of estrogen to vaginal health and sexual function. We’ve also discussed various options for replacing estrogen and enhancing vaginal comfort. And we explored the latest thinking about hormone replacement therapy (HRT).

In a nutshell, estrogen is critical to sexual comfort and function, and that’s the hormone we lose during menopause. Most therapies revolve around replacing estrogen to treat menopausal symptoms.

For many years, Premarin was the estrogen replacement of choice. This is a synthetic estrogen made from the urine of pregnant mares, which, according to the Harvard Women’s Health Watch,  “contains a mix of estrogens (some unique to horses), steroids, and various other substances.”

Bioidentical hormones, on the other hand, are defined by the Endocrine Society as “compounds that have exactly the same chemical and molecular structure as hormones that are produced in the human body.” Bioidentical hormones are usually extracted from plant sources.

Pharmaceutical companies manufacture many brands of bioidentical estrogens, such as Vivelle, Elestrin, Divigel, Evamist and one brand of bioidentical progesterone (Prometrium). These are FDA-approved bioidentical hormones. About 95 percent of my patients are on these FDA-approved bioidentical hormones.

All hormones, whether they are synthetic or bioidentical, are labeled with the black-box warnings mandated since the massive Women’s Health Initiative study linked slightly higher rates of breast cancer, blood clots, and heart disease to hormone replacement therapy.

So far, so good.

Confusion enters in when bioidentical hormones are custom-compounded by pharmacies. Sometimes there are good reasons for a doctor to prescribe a custom-compounded hormone, if a patient is allergic to some agent in the FDA-approved hormones, for example, or if her dosage can be lower than those produced by pharmaceutical companies.

But hormones made by custom compounders aren’t subject to FDA oversight, nor must they adhere to FDA-approved processes. These custom hormones don’t come with black-box warnings because they don’t fall under the FDA umbrella.

In actual practice, there may not be that much difference between custom hormones and FDA-approved hormones. According to the Harvard Women’s Health Watch, in a 2001 random test of 37 hormone products from 12 compounding pharmacies, almost one-quarter (24 percent) were less potent than prescribed, while 2 percent of FDA-approved products were less potent.

The other problem with custom compounds is cost. Health insurance usually doesn’t cover them, so the regimen gets expensive very quickly.

While custom compounds may be a helpful option for some women, the controversy surrounds the claims about them made by celebrities like Suzanne Somers and even by some clinicians.

In the introduction to her book, Somers writes, “This new approach to health [bioidentical hormone replacement therapy] gives you back your lean body, shining hair, and thick skin, provided you are eating correctly and exercising in moderation. This new medicine allows your brain to work perfectly and offers the greatest defense against cancer, heart attack, and Alzheimer’s disease. Don’t you want that?”

Well, who wouldn’t? But like most claims that sounds too good to be true, so is this one.

The truth is that bioidentical compounds, no matter how “natural and safe” they may sound, are still drugs. There’s no scientific evidence that their effect is any different than synthetic hormones. Also, because hormonal levels vary from day to day, even from hour to hour, attempting to customize hormonal treatments is tricky business. “There’s no stable ‘normal’ value at all for salivary or blood levels of these hormones or levels that correlate with symptoms,” says the Harvard Women’s Health Watch.

The current medical advice is to take the lowest possible dosage of any hormone—synthetic or bioidentical—for the shortest period of time to alleviate menopausal symptoms. There is, unfortunately, no way to turn back the clock—”natural” or otherwise. In the meantime, the hormones that work for a woman can significantly improve her quality of life.

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Absolutely you can, and I often recommend that women use both. Both vaginal estrogen creams–like Estrace–and vaginal moisturizers–like Replens–are typically used twice a week. Because each needs to be absorbed and, frankly, because it might otherwise be a little messy, I recommend that you alternate application. You might, for example, use the Estrace on Monday and Thursday and the Replens on Tuesday and Friday.

Glad you’re taking care of yourself!

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Estrogen is the queen of hormones. From our brains to our bones to our bottoms, estrogen keeps our systems regulated, lubricated, elastic, and running smoothly. Estrogen doesn’t just trigger sexual development in our breasts, uterus, vagina, and ovaries (although it does that, too), but it also regulates the production of cholesterol in our liver; it affects mood and body temperature from the brain; it protects again loss of bone density; and it keeps our sexual organs responsive and functional.

Estrogen is actually a category—a group composed of three chemically similar hormones. Estrone and estradiol are mostly produced in the ovaries, adrenal glands, and fatty tissue of all female mammals. Estriol is produced by the placenta during pregnancy. These estrogens circulate in the bloodstream and bind to receptors located throughout our bodies.

Not surprisingly, most of those estrogen receptors are located in the vulva, vagina, urethra, and the neck of the bladder, and that’s  why we talk about estrogen so much in this blog and at MiddlesexMD. It’s the critical hormone that keeps our sexual apparatus healthy and functional.

Before menopause, a healthy vagina has

  • thick, moist “skin,” or epithelium
  • tissues with many folds (rugations) that allow the vagina to expand and become roomier
  • differentiated layers of cells—superficial and intermediate
  • secretions from the vaginal walls and cervix that help maintain a slightly acidic pH balance
  • an increase in blood flow and lubricating secretions during sexual arousal
  • toned pelvic floor muscles that help to hold our internal organs in place

So, ladies, it’s easy to see that when our estrogen levels drop dramatically during menopause, virtually all of us will experience significant change to our vulvovaginal tissue. The umbrella term for that change is “vulvovaginal atrophy.” Here’s what happens to our genital area when we lose estrogen:

  • the epithelium becomes pale, thin, and more likely to tear
  • the vagina shortens and narrows
  • vaginal walls lose rugations (those folds or pleats) and become smooth
  • cells become less differentiated—there are more intermediate and fewer superficial cells
  • the vagina becomes dry without secretions to maintain a good pH balance or to lubricate during sex
  • the vulva shrinks and pubic hair thins
  • the pelvic floor loses muscle tone, so organs relax and sometimes sag (prolapse)

It’s not a pretty list, but it’s our new, postmenopausal normal. Vaginal atrophy can bring more frequent vaginal and urinary tract infections as well as more painful sex. And since painful sex usually means less sex, both our relationship and our quality of life can suffer.

Fortunately, as we’ve discussed many times in this blog and at the MiddlesexMD website, there are simple and effective ways to ease the effect of estrogen loss. These include using moisturizers and lubricants or topical estrogen products, doing our kegels, and talking to our doctors about vulvovaginal changes.

Losing estrogen and its beneficial effects is inevitable as we grow older, but losing function, sexual or otherwise, isn’t. Sex—and life—can be just as enjoyable. They just take more maintenance now.

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You may not be able to leap up from a lotus position in a single bound. (Heck, you may not even be able to get into a lotus position.) You may find your back a little cranky when your two-year-old demands to be carried. Most disappointing of all (to your love life, anyway), you may find yourself falling into an exhausted stupor every night at the same time as your kindergartner.

For all the delights of motherhood, it’s a different ballgame at midlife.

And more moms are having their first babies later in life, after they’ve established their careers and their relationships. According to government statistics, first births to women over 35 increased eight-fold between 1970 and 2006. In 1970 one in 100 first babies was born to a woman over 35. In 2006, that number was one in twelve!

And that means that many women are entering menopause while still in the throes of active parenting. So, in the midst of diapers and runny noses, perimenopausal women with young children are likely to ignore the effects of menopause, and specifically the effects of menopause on their vulvo-vaginal area.

Most women who come into my office know about mood swings and hot flashes, but they don’t know that menopause compromises their sexual apparatus as well. But keeping these parts operating smoothly is important to your sex life and, thus, to your quality of life. (And yes, you will have a sex life again.) So, in addition to everything else you have to do, establish a healthcare regimen for your vagina as well, because you’ll continue to use it long after the kids have grown and gone.

Here’s what happens to your vagina during menopause:

When your estrogen supply begins to diminish your skin and other tissues lose collagen—the substance that keeps skin supple and youthful-looking. Loss of collagen causes vaginal and genital tissue to become thin and dry. You may also notice that your vagina no longer lubricates well when you become aroused. This is called vaginal atrophy, and it can make sex very uncomfortable. Vulvo-vaginal atrophy can also exacerbate urinary tract infections and cause burning, itchy genitals.

Fortunately, this condition is easily remedied, but your vagina and pelvic floor will need ongoing attention to stay in shape. If you’re noticing any of these menopausal symptoms, talk to your doctor—yes, about sex. Trust me, doctors have heard it all.

Generally, a maintenance plan for a healthy vagina and pelvic floor involves

  • Moisturizers. Use vaginal moisturizers, such as Yes or Replens, regularly—two or three times a week. Vaginal moisturizers help hydrate vaginal walls and maintain a normal pH balance. Your doctor might also prescribe a topical estrogen, which restores vaginal tissue to pre-menopausal condition without being absorbed into your system.
  • Lubricants. Apply lavishly before and during sex to ease discomfort and can add an element of fun.
  • Kegels. These muscle-tightening exercises will tone your pelvic floor, which keeps your internal organs in place, makes orgasm more powerful, and reduces stress incontinence, that lingering embarrassment that often accompanies vaginal birth.

Finally, have sex. I know you’re not in the mood. I know you’re tired, not to mention being pulled in a thousand directions, but regular sex is the best prescription for maintaining vaginal health and capacity. As we say at MiddlesexMD, “use it or lose it.”

It may not be the most romantic solution, but here’s how one late-in-life mom schedules sex with her hubby: “I’d just suggest, ‘Hey, tomorrow night, after we put [the kids] in to bed and get them asleep, let’s go right into the bedroom.’ Sometimes I’d do this more than a night or two in advance. Not romantic in the least… but in practice, the planning didn’t diminish the enjoyment.”

The same vaginal maintenance advice applies to single moms at midlife, too. You may feel like you’re in a sexual desert with zero chance of scoring in the love lottery. You may have forged an uneasy peace with being alone for a long time. But consider this: it’s a lot easier to maintain your sexual apparatus than to repair it after the fact. And you don’t want to find your Prince Charming only to discover that your vagina isn’t willing or able.

In addition to the three-part vaginal health program I outline above, I advise single women to to self-stimulate regularly (you can use a vibrator with lubricant). This is important in maintaining vascular and nerve pathways to the vulvo-vaginal area.

Whether you’re single or partnered, being a mom at midlife is complicated. In the long run, educating yourself about the physical changes you may already be experiencing will help you to stay healthy and responsive. You owe it to yourself.

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