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Archive for March, 2012

In a post last week we established that folks over 50 are reentering the singles scene with seriously outdated information about the sexually transmitted infections (STIs) that have become commonplace since their own prom nights.

When it comes to older people and STIs, “don’t ask; don’t tell” is the MO. Doctors don’t think to ask Grandma about her sex life, and Grandma sure ain’t talking.

“What we are really witnessing with trichomonas, especially in older women, is that no one ever looked, no one ever tested and diagnosed, and no one is really getting treated, so the infection persists year after year,” said Charlotte Gaydos, a professor at Johns Hopkins School of Medicine in a news release.

And what is true for trichomonas, is true for all the other nasty little STIs— These infections respect neither age nor social status. Anyone can get an STI. Even Grandma.

So, in this post and one more, we’ll give you a primer on the most common STIs circulating now. (Yes, this is the short list.) The topic is complex and evolves quickly, so if you’re sexually active and especially if you have a new partner or several partners, talk to your doctor about prevention and getting tested.

Finally, if this information doesn’t scare the bejeesus out of you, then you have a higher tolerance for risk than is probably good for you.

First, a few general observations.

  • Get an annual pelvic exam. New guidelines from the CDC now recommend annual pelvic exams and Pap tests every three years. But if you have a new partner, tell your doctor.
  • If you have a new sexual partner, insist on using a condom (properly) until you are both absolutely certain nothing is getting passed between you. It can take several months for infections like HIV to show up on a test.
  • Both you and each new partner should be tested for STIs. (See the last post.)
  • Drug and alcohol use impairs judgment and leads to more risky sexual behavior. (Yes, that means you.)
  • Condoms help, but they’re never 100 percent effective. Some viruses can be on places not covered by the condom.
  • One infection reduces your ability to fight off others. This is especially true with HIV, that’s why it’s important for both partners to know their health status.
  • Many infections have no symptoms. Someone can have, and spread, an infection without knowing it.

 Bacterial infections

These are the most common bacterial STIs. These are much easier to detect and treat in early stages. Without treatment, they can do a lot of damage and are harder to get rid of.

Trichomoniasis

This is really a parasite, but it’s treated with antibiotics. And, ladies, this is Grandma’s infection of choice, since women over 50 have the highest rates of infection.

How common is it?

Trichomoniasis has become the most common curable STI in the U.S. with about 3.7 million people infected. In one recent study, of those testing positive for trichomoniasis, 13 percent were women over 50; 11 percent were over 40. By contrast, 8.3 of women in their 20s tested positive. Based on these findings, researchers are recommending routine screening for sexually active women over 40.  

How do you catch it?

Trich is passed from penis to vagina or vice versa. It doesn’t seem to infect other parts of the genitalia. Latex condoms help prevent infection.

What are the symptoms?

Seventy percent of women have no symptoms. Others may experience a greenish vaginal discharge, itching, inflammation, redness, or burning with urination in the month following the infection. Symptoms may come and go. The concern for older people with trich is that they are more susceptible to catching other STIs. It’s easily cured with antibiotics.

Chlamydia

How common is it?

Very. Rates of Chlamydia have more than doubled in the past decade, and it’s probably greatly under-reported. The U.S. Centers for Disease Control and Prevention (CDC) estimates that 2.8 million new cases occur annually.

How do you catch it?

Through oral, anal, or genital sex. Latex condoms are effective at prevention. Those with multiple sex partners should be tested regularly.

What are the symptoms?

Most women (70 to 80 percent) have none. The infection is particularly concerning for younger women, who are more susceptible to becoming infected and because, left untreated, it causes PID and infertility.

Chlamydia is easy to treat with antibiotics, but all partners must be treated to prevent reinfection.

Gonorrhea

How common is it?

The CDC estimates that about 700,000 cases of gonorrhea occur every year, although only about half are reported.

How do you catch it?

Gonorrhea is becoming known as a “super-bug,” one that’s very resistant to antibiotics. Because of this, doctors are advised to prescribe two kinds of antibiotics. It’s spread through contact with the penis, vagina, mouth, or anus of an infected person. The CDC says, “Latex condoms, when used consistently and correctly, can reduce the risk of transmission of gonorrhea.”

What are the symptoms?

Women tend to have very mild symptoms or none at all. Urination may be painful, or there may be vaginal discharge. Left untreated, the bacteria, which tends to flourish in the urethra, cervix, fallopian tubes, and uterus, can cause a massive internal infection called pelvic inflammatory disease (PID).

Syphillis

How common is it?

According to the CDC, there were 36,000 new cases of syphilis in 2006, and rates have held steady since, so this isn’t the most worrisome STI.

How do you catch it?

Through contact with the syphilis “chancre” or sore. These can be on the genitals, anus, vagina, or in the rectum. But they can also be on the mouth and lips. Condom use may not offer complete protection if the chancre isn’t covered by the condom.

What are the symptoms?

First stage: 10 to 90 days after contact, a hard, round, painless sore (chancre) appears where the bacteria entered the body, usually on the genitals. This heals by itself within a few weeks.

Second stage: A more extensive rash appears that may be brown or pinkish, often on the palms of the hands and bottom of the feet. It may be accompanied by flulike symptoms: fever, headache, weight loss. These, too, go away.

Last or latent stage: Without treatment, the disease may remain asymptomatic for 10 to 20 years, all the while the infection is slowly damaging internal organs and the neural system.

Syphilis is easy to treat with antibiotics in early stages. Later stages are very hard to treat.

Had enough?

We’re only halfway through. In the next post, we’ll discuss the viral diseases—you know, the kind that can’t be cured.

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There are a number of pieces to this puzzle–we women are complicated! First, because your hysterectomy was “complete,” you no longer have ovaries, which are a major source of testosterone (up to 50 percent) for women. Losing that testosterone can be a major hit to women’s desire, arousal, and orgasm. Some women benefit from adding back testosterone, but it’s not FDA-approved in the U.S. and not all practitioners are familiar or comfortable with prescribing it for women.

If you’re taking oral estrogen, some complicated biochemistry is at play that can further decrease your testosterone. Replacing estrogen by a means other than oral–skin patch, spray, gel–is important.

If you’re not taking estrogen, orally or otherwise, that may be a contributing factor, too. Losing estrogen leads to less blood supply to the genitals, which makes arousal and orgasm more difficult.  Localized vaginal estrogen works for many women, and it’s not absorbed system-wide.

Beyond the hormonal pieces of this puzzle, I often recommend warming lubricants or arousal oils, which use a stimulant to bring more blood supply to the genitals. Using a vibrator can also help; the more intense stimulation can make a difference. And I encourage women to explore self-stimulation: What you require now may be different from what it was, and the better you understand yourself, the more you can help your partner meet your needs.

Best of luck! It will be worth the time and effort to revive this part of yourself!

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You say the skin is becoming lighter and sometimes is dry, sometimes moist or itchy. That sounds completely consistent with the changes of vulvovaginal atrophy (VVA), which results from the absence of estrogen. It’s a gradual progression; it may not be particularly bothersome at first but may be more noticeable in the months and years to come.

The consequences of lost estrogen are often most noted in the vulva or vaginal tissues. Our bodies have lots of estrogen receptors, meaning estrogen plays a role there–from head to toe. But there are more estrogen receptors concentrated in the vagina and the vulva than in any other part of the body.

In and of itself, VVA doesn’t require treatment. If you have uncomfortable symptoms, there are treatment options, including localized estrogen, Neogyn vulvar soothing cream, vaginal moisturizers, and more.

You might also be aware that natural vaginal pH levels rise in the absence of estrogen, which means a woman can be more susceptible to infections. Symptoms to watch for are discharge, irritation, and/or odor.

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Sit down, Girlfriend. We need to talk.

Remember those uncomfortable discussions you had with your kids back in the day? You know, the birds-and-bees and how-not-to-get-pregnant talks?

Well, now it’s your turn to listen. This is your middle-age sex talk.

At some point in life, you’ll probably be alone, demographics and life expectancies being what they are. Maybe you already are. Maybe you’re newly divorced. Or widowed.

And maybe, after being married for many years you’re not ready to write off a relationship—or sex—for the rest of your life.

That’s great! We’ve already discussed the health benefits of sex. And we’ve talked about the research that shows that older women really like sex and are good at it.

But the singles scene is now a completely different ball game from those long-ago days when you were a player. “When I was younger we only worried about getting pregnant or getting crabs. Now that I’m divorced, I realize it’s a whole new world!” said a woman on one health website.

“In my practice I see a lot of older single women who don’t know the rules of dating,” says Mary Jo Rapini, psychotherapist and MiddlesexMD advisor. “They’re looking for someone to desire them again, and they’re much too easy with letting sex happen. They aren’t comfortable with demanding that the guy wear a condom.”

You may not need protection against pregnancy any more, but you sure need protection against a cornucopia of STDs that has flourished since your first date.

STDs affect every age group, but rates of infection are growing fastest among older people. According to the Centers for Disease Control, 15 percent of new HIV infections are in those over 50—and death rates are rising, too. In 2008, the journal Sexually Transmitted Infections noted that infection rates among those over 45 had doubled in less than 10 years. Research at Indiana University in 2010 indicated that condom use was lowest in that age group. Maybe there’s some connection there?

Besides general lack of awareness, a few physiological factors make it easier for older women to become infected. The thin, dry vaginal walls that accompany loss of estrogen create small tears and microscopic vaginal bleeding during sex, thus offering a warm welcome to invading nasties. Further, our pH balance tends to be less acidic after menopause, creating a friendly environment for bacterial infection.

So what’s a newly single older gal to do?

Empower yourself, says Rapini. Take a page from your kids’ playbook and insist on safe sex. This isn’t about being difficult or demanding, it’s about your health, and you have every right to safeguard it.

Here are the safe sex rules:

  • Wait to have sex. Isn’t this the advice you give your kids? What’s the rush? Date for a while and get to know the person. A lusty first date could fizzle on the second or third. And then you might be stuck with an unpleasant reminder of a fleeting passion.
  • Get tested. And insist that your partner does as well. How can I ask that? you’re thinking. Girlfriend, this is how you empower yourself. You don’t take chances. “If the guy has nothing to hide, he shouldn’t resist.” says Rapini.

Once you’ve decided that sex is on the horizon, you could say something like, “I’m getting tested for STDs, and I think it’s a good idea for you as well.” That creates a level playing field and opens the door to discussion later.

  • Share the results of your screening. This gently opens the door to honest talk about sex. If you’ve never talked openly about sex before, it’s time to change. “If you stay passive you’re less likely to have good sex.” says Rapini.
  • Continue to use condoms for at least six months after a screening. Some infections, such as HIV, don’t show up immediately. Always keep latex condoms with you, just in case. If a condom is used correctly, it provides 90 percent protection. It’s less effective against the genital herpes virus or the HPV virus because those viruses are more widespread on the genital area.
  • Take care of your vagina. We’ve talked (and talked) about good vaginal hygiene. In addition to the infection-fighting properties of a healthy vagina, the sex will be better and more comfortable, too.
  • Keep communicating. This may be uncomfortable at first because our generation didn’t talk about sex, but this is the time of life for discovery. Learn what you like, and learn to ask for it.

Empowerment, remember? Respect yourself enough to insist on safe sex.

Let us know how it goes.

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We’ve discussed the research: Older women “do it,” and like it, a lot! Beneath the sheets, we’re a lusty bunch, but get out on the streets, and we become invisible. No checking-you-out eye action; no swivel head. It’s hard even to get the attention of the guy in the hardware store if a young blonde is looking confused.

Older women are supposed to be genderless and unassuming. Certainly not sexy. Often, not even visible.

That’s a psychological sucker-punch to the self-image if there ever was one. So we wonder why, once we’ve begun (or completed) “the change,” we struggle with feeling all confident and attractive? When we are no longer fertile or full of hormones, are we still sexual? While we’re coping with a changing metabolism and whipsawing emotions are we still attractive?

In our time and culture, menopause is embarrassing and slightly distasteful. It’s synonymous with loss of fertility, loss of hormones, unmentionable changes “down there,” and growing old. Far from being regarded as wise and valuable, older women are often viewed as useless and sexless.

Maybe that cultural aversion is, in part, why we ignore things like incontinence, lack of libido, and painful sex—sometimes for years—because it’s embarrassing to admit that we may be having trouble with “the change.” Or experiencing menopause at all.

Wasn’t aging supposed to be graceful? Aren’t these supposed to be the golden years?

Without doubt they are. But to enjoy this time of life, we have to reject the negative voices all around us and in our heads. Maybe the way we look and, I hope, the way we look at life has matured. And maybe the way we do sex has changed. Maybe we need a little more time and a little more stimulation. Maybe we need more finesse and a few aids. But we still got it going on, girlfriend.

Here are some tips to get your sexy on:

  • Adjust your attitude. Sexy begins in your head. See yourself as sexy and attractive, and others will too. But even more important, what do you care how others see you? As one very sexy middle-aged woman said, sexy at midlife is “being sure enough of yourself to do, feel, act, dress, say what you want and not giving a flipping flyer what anyone thinks—and they often think you are cool!” So, Rule Number One: don’t give a flipping flyer.
  • Take care of yourself. This is the time to stick to those New Year’s resolutions. Really. Lose weight. Eat well. Exercise. Looking your best gives you an incredible confidence boost, and it makes you feel vital and vibrant as well. This might include a little fashion makeover as well. Nothing like flattering clothes and the right hair for a little emotional pick-me-up.
  • Enjoy life. Be interested in the world around you. Men (and women) are attracted to vital, interesting people.
  • Laugh. It relieves stress and releases endorphins. It makes you look attractive.
  • Have sex. Often. Think about it. Plan on having sex. Adjust to your changing physicality. (Talk to your doctor if you have specific problems, such as pain or lack of desire.) Don’t buy that cultural message that you’re no longer in the game. You still are in the game.
  • Wear red (but only if the color’s good on you). Men think women in red are hot. (And conversely, women are more attracted to men who wear red.) That’s what the research says.

I’ll leave the last word to a man who writes, “Now I check out the middle-aged women when I hit the grocery store, in the coffee shop, when I’m out running. I’m looking for that sexy confidence, that wisdom, that I’m vibrant and alive and I don’t care what you think about me sort of attitude.

So, ladies, what are you waiting for? Get your sexy on, for your special partner or for the potential one who might be checking you out in the produce aisle.

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You’re right to be concerned, since the vulva and opening to the vagina can be easily irritated–and more so after menopause without estrogen therapy. Vitamin E oil can be used both for massage and lubrication. Liquid Silk is a lubricant that many women find soothing applied in the vaginal area. Most things that are flavored or heavily scented have the potential to be irritating to that delicate skin.

We’ve also liked Zestra, an arousal oil designed to use externally on the vulva. Its warming characteristics can be helpful in “reawakening” sensations as part of an intimate massage. As with any warming product, try just a small amount first to be sure it isn’t irritating.

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What makes sex feel so good? What ignites passion and sustains attachment? What is it that makes your heart flutter? And how can you keep those feelings alive, especially in the bedroom, after 10—or 40—years?

Turns out passion and attraction—all the stuff of poetry, song, and story—are the product of your most ancient brain—the limbic system—which you have in common with lots of other animals and which regulates a chemical stew of neurotransmitters. Emotions, drives, impulses, and desires originate in the limbic system. This part of the brain is wired for pleasure and passion, and it operates independently of our conscious choice or will.

Now, just for the record, I refuse to believe that our primitive mammalian brain and a bunch of electrochemical impulses is all there is to love and romance, but a good part of what maintains a relationship and makes sex feel good is indeed all about the chemicals.

The neurochemicals in the brain have two evolutionary goals: to encourage reproduction and then to help maintain a sufficiently nurturing environment for offspring.

Sex is supposed to feel good so that you have lots of it and fulfill your evolutionary mandate to multiply. We wouldn’t last long as a species if sex felt bad. But lots of casual sex and many partners is counterproductive for the long and challenging process of raising children. So your neurochemical circuitry is finely tuned to make sex pleasurable, but also to reinforce the bonds with your mate.

And even though your children may be grown and gone, you still operate within that chemical framework. So you might as well understand it and use it to your advantage.

If you find something pleasurable, sex for example, or chocolate—or sex and chocolate—it’s because your limbic system releases a rush of dopamine when you indulge in what you crave. Dopamine drives people to fulfill their cravings. In one well-known study a rat receives a spurt of dopamine every time it presses a lever. Soon, the rat is obsessively pressing the lever, no longer eating, copulating, or tending to its pups.

Orgasm releases a big surge of dopamine.

Like the rat, you can’t exist on that tingly dopamine high, however good it feels. When there’s too much dopamine in the circuit, the brain begins to reduce the levels it produces and to shut down dopamine nerve receptors. That’s why addicts need an ever-increasing “fix”—more of the drug, sex, porn, or gambling—to reach the same high.

So, immediately after orgasm, dopamine levels drop and prolactin is released to calm things down, especially in males. Prolactin is the dopamine antidote. This is what regulates the “recharge” time in younger men (remember when?); it produces a feeling of sexual satisfaction—and sleepiness, which is why men tend to roll over and fall asleep.

So, don’t take it personally; it’s just the prolactin talking.

Endorphins are also released during sex. These are opioid-like neurochemicals, like morphine and heroin, that block pain and induce feelings of euphoria. They’re also released when you laugh or exercise. (That’s what’s responsible for the “runner’s high.”)

Vasopressin, another neurochemical released during sex, encourages bonding behavior. When vasopressin is suppressed in male prairie voles, a mammal that forms monogamous pairs, they tend to lose their sense of connectedness and become disinterested in their mate.

But the most important chemical that balances the irresistible dopamine “high” is oxytocin. This is the “cuddle hormone”; it makes you feel close and loving. It calms you and relieves stress. And unlike dopamine, you can never get enough of it.

Oxytocin is released during sex, but it’s also released during labor and lactation to create that instinctive bond between mother and baby. During sex, it reinforces your connection with your mate. It offsets the opioid-like cravings of dopamine and endorphins while making the two of you feel close and receptive to sex.

Evidence even suggests that when you have more oxytocin in your system, more nerve receptors are created just to accommodate them. So be sure to laugh, exercise, make love, and cuddle before and after (if your mate can stay awake) to create lots of receptors for your increased oxytocin levels.

And in order to increase your sensitivity to the dopamine and endorphin “high,” cuddle without the sex occasionally. Take a little sex break so that when you come together, your pleasure circuitry is primed and ready.

Your body is hard-wired for sex in the most primitive levels of the brain. When you make love, you’re producing the most potent chemicals your system is capable of. You are a sexual animal. Celebrate!

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Last month MiddlesexMD advisor and psychotherapist Mary Jo Rapini shared some advice about how to restore your sense of sexual self after divorce. That conversation led to another, about some of the unexpected challenges we face when we re-enter the world of dating after an absence of… well, it could be decades! 

My first advice for people getting back into dating after a divorce is to tread slowly. It’s a whole new world out there, and if you’ve been married for some time, the dating scene is sure to overwhelm and frighten you. You’ll know you’re ready to begin when you no longer feel like you need a partner, but would like to enjoy another’s company. When you’re lonely and riddled with pain, you don’t make a good partner; that’s not the time to look for someone. Sacrificing your own physical and emotional health to get a “fix” of feeling desired again is never a good idea. But be assured that time is only a temporary patch.

When you’re ready to start dating, tell friends and colleagues you respect that you’re looking or open to meeting new people. People you respect have respect-worthy friends; they’re usually your best option for getting a date with someone you’ll like. If you don’t have many friends, you might start by searching out groups you could join to meet other single people. Cooking classes or groups, poetry readings, church groups, plays, and sporting events all provide opportunities to connect with others who appreciate the same things you do. Being with others helps build your confidence and provides feedback about how you present and appeal to others. Being married may have enabled you to not focus on your looks, your mannerisms, and your lifestyle. Dating forces you to evaluate all of those qualities that you may have taken for granted or not explored.

Lots of people have been trying out online dating. It’s great for letting you “date” on your own time, ask a lot of questions, and get to know someone in the comfort of your own home. It’s scary because it can provide a “cover” for someone to lie, take advantage of you by saying what you want to hear, and to serial date without you knowing. You need to be cautious and smart. Online dating does give you a chance to experience dating, though, before you take a risk and actually dress up and meet up. I encourage women to focus on the experience rather than any specific outcome. I date online only vicariously—as a relationship psychotherapist—but here are the things I see helping my patients avoid problems:

  • Stay anonymous with your user name, personal information, and phone number—until you and only you decide you’re comfortable giving out that information. Once it’s out there, you can be harassed and pressured. If you don’t know a person enough to trust him, don’t.
  • Make decisions cautiously. Don’t move too fast; one conversation is not enough to commit to meeting someone in person. The same behaviors that work well for physical dating are valuable with online dating.
  • Look at several different photos. Who is the person with? Is anyone cut out of the photo? Has it been photo-shopped or otherwise altered? Why? Ask questions. I would like to say it doesn’t matter what we look like, but that would be a lie. Most people cannot trust someone until they see a photo.
  • Talk on the phone at least once—hopefully more—before you meet someone. A voice tells you a lot more about a person. Online dating is a little bit like putting a puzzle together. The pieces of a person’s life should make sense when you see them together.
  • Take your time before meeting—one of the great assets of online dating. When you decide to meet, do it at a public place. Tell your best friend or several people where you’re going and your date’s name and phone number. Trust your gut when you see the person. You can always back out at the last minute. If the person tries to pressure you or argues with you in any way about meeting you, that’s a red flag. Don’t go.
  • Always take yourself to the meeting place. Never let them pick you up and don’t have someone drop you off unless they can come at any time to pick you up. This is not the time to be vulnerable. If you are meeting someone from another city, state, or country, make your own travel plans. Don’t tell the person where you are staying or your travel details. Set a meeting time and place and meet there.
  • If, at any time, you feel you are unsafe with this person, call the police. They will give you counsel in regards to what you should do. One of my patients decided to meet someone she met online in Colorado. She became frightened when, after dinner, she went to his place and he wanted to have sex. He was into asphyxiation and almost killed her. She told me she had a bad feeling in her gut when she met the guy, but she didn’t honor it.

Dating after a divorce is all part of the journey you find yourself on after signing the papers. It isn’t easy, but it’s an opportunity to grow and explore. Stay open, and allow yourself to really experience what happens. Dating when you’re older has its advantages. You are wiser and understand the fragility of relationships. You no longer need a person to fulfill you; you are looking for one to share your life with. Take your time, and enjoy the experience.

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