Archive for April, 2012

When was the last time your doctor asked you how your sex life was going?

I thought so.

In a new study, a team from the University of Chicago surveyed over a thousand OB/GYNs about whether they talk with their patients about sex. The results may not surprise you, but they won’t reassure you, either.

  • 63 percent routinely ask whether their patient is sexually active. (Good, but fairly superficial.)
  • 40 percent routinely ask if the patient is having any problems regarding sex. (Which means that 60 percent don’t ask about sexual problems.)
  • 28.5 percent ask about sexual satisfaction. (Which means that two out of three doctors don’t ask.)
  • 28 percent ask about sexual orientation or identity. (Yikes! Two out of three don’t even know if their patient is gay or bisexual.)
  • 13.8 percent ask about sexual pleasure. (Which means that 86 percent don’t ask whether the patient enjoys having sex.)

Even more distressing was that 25 percent of OB/GYNs reported expressing disapproval of a patient’s sexual practices. Foreign doctors, older doctors, and very religious doctors were more likely either not to address the issue of sex or to express disapproval. Female doctors and those whose practice focuses on gynecology rather than on delivering babies were more likely to do some sexual assessment, although it was often insufficient.

Dr. Stacy Tessler Lindau, a practicing OB/GYN and lead researcher in the study, points out that OB/GYNs are the most appropriate health care provider to be asking these questions, and if they aren’t, it’s unlikely that anyone else is. Which means, as we have found repeatedly, that women tend not to mention sexual problems, to assume that a doctor can’t help anyway, and to suffer with or adapt to sexual problems on their own.

Doctors should be talking about sex with their patients because

  • Sex is an intimately linked to overall quality of life and the quality of one’s relationship.
  • One-third of younger women and one-half of older women report having some sexual issues, from lack of desire to painful intercourse
  • A change in sexual patterns can indicate an underlying health problem, such as depression or thyroid problems.
  • Women with ongoing sexual issues are more likely to feel self-conscious, isolated, embarrassed, ashamed, or guilty.
  • Assuming that a patient has a heterosexual orientation is alienating to patients who are lesbian or bisexual and can result in miscommunication and misdiagnosis.
  • Common medications, such as those for depression and breast cancer, for example, can cause sexual problems, such as low libido. Women are often not told about sexual side effects of medications and are therefore unprepared to cope with them.

The researchers hypothesize that doctors don’t talk about sex because, like everyone else, they’re embarrassed or they may worry about embarrassing their patients. Talking about sex isn’t part of their medical training, and although they may treat a woman’s sexual organs, they aren’t equipped to assess and treat her sexual problems.

So what’s a frustrated patient to do?

Take the initiative, counsels Dr. Lindau. If you trust your doctor, but he or she hasn’t asked about your sex life, you can, and should, begin the conversation.

  • Formulate your questions ahead of time. What, exactly, do you want to ask your doctor about sex? Do you have specific issues, such as painful intercourse or low libido? Are you anxious about entering menopause and need information about what to expect? Write down your questions and be as specific as possible.
  • Acknowledge your discomfort, advises Dr. Michelle Curtis. It clears the air. “I know this is a little embarrassing, but I have some questions about sex I’d like to discuss.” Don’t worry about embarrassing the doctor, says Dr. Curtis. It’s his or her job to answer your questions.
  • Empower yourself. The medical profession will change as women take responsibility for their own sexual health and begin asking questions and expecting thoughtful answers. You can ground yourself in basic information with websites like this one or others backed by solid medical organizations, such as the Cleveland Clinic or Mayo Clinic. Then you can approach your doctor with good, informed questions.

And if your doctor doesn’t respond in kind, avoids your questions, or seems uninformed, you can consider finding another doctor. We’ll discuss that process in a future post.

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Dear beloved partner of mine:

If you read my last letter (you did, right?), then maybe you understand how I feel—and how to make me feel better—sexually speaking.

So let’s stop beating about the bush. (Music to your ears, I know.) I’m going to get very specific about how to turn me on. But I’m hoping that if I take this step, you’ll reciprocate, and maybe we can begin talking about sex more openly, about what we each like, and about how to make it good for both of us.

Prime the pump. Always remember that, for a woman, sex begins in the mind and imagination. Use that to your advantage. Begin early. Make the coffee and bring it to me in bed. Leave me a provocative note in the morning. Send me a sexy text. Bring home lovely wine and chocolate. Help me get my head in the game.

Finesse the foreplay. I recently read that it takes a woman an average of 20 minutes to reach orgasm—and it takes a man four! Those numbers may be optimistic for both of us these days, but they illustrate one important difference between Venus and Mars: I need time! Besides, we’re sitting on Golden Pond now. What’s the rush?

Try starting in a different room. (Variety is always spicy.) Whisper sweet nothings. Tell me I’m beautiful. Show me that you desire me.

So once we get down to business, don’t just go for the goal posts: tease me. Use light touch. Use your tongue. Use your imagination. Experiment. Try running your hands over my inner thighs, tickle my neck. Try stimulating my perineum. (That’s the spot between my vagina and my anal opening.) Once I begin to steam up, hone in on the erogenous zones—my breasts and vulva. Lightly touch, lick, or kiss. Back off and do it again. Ask me to show you how I like to be touched.

Many ways to score. Despite all you’ve heard about how hard it is for women to reach orgasm, we’re actually equipped with several ways to do it. In fact, according to an article in Everyday Health, “researchers have even found a nerve pathway outside of the spinal cord, through the sensory vagus nerve, that will lead a woman to orgasm through sensations transmitted directly to the brain.”

Pretty fancy, huh?

But the surest way to orgasm for most women is through the clitoris—it’s the tail that wags the dog. And while it may take some practice to get it right, that little number isn’t choosy about the medium. Both oral and manual stimulation work just fine.

I know you’re not completely clueless, but let’s run over some technique. First, remember the tease. Don’t dive right in and go for gold. Kiss my abdomen and thighs, then move to the vulva and its inner lips. Gently lick or kiss. Explore with your tongue. Lick my clitoris lightly, then move away. Then come back. Don’t lick one spot too intensely or too long, because it just becomes numb. Let me know you like this. Pay attention to how I’m responding. Do I seem to be getting turned on? You can ask, you know.

When I’m good and ready, you can focus on the clitoris. At this point, a firm, repetitive licking should do the trick. You can also place your finger in my vagina at the same time. Maybe you can find the elusive G-spot. I’ll let you know. Or, you can caress my breasts as I’m coming into full-blown orgasm. You can also try to stimulate my perineum and see if I like that.

Another move (only slightly acrobatic) would be to move up to missionary when I begin orgasming clitorally and get your own orgasm started. (You should be pretty turned on by now—it’s been more than four minutes.) It’ll feel pretty good to me.

If this is a little overwhelming, or if you need more detail, I’ll buy you the book She Comes First: A Thinking Man’s Guide to Pleasuring a Woman by Ian Kerner.

Good positioning. Finally, let’s not neglect positions that might work better for me than our standard missionary. We could try what the kids call the “reverse cowboy,” or the doggy-style, rear-entry position. Or maybe I could sit on your lap? That might hit some different nerve endings, plus we can get real cozy.

We could also try some of those fancy pillows to help us get into all kinds of positions. (And to support our less-than-agile parts.)

And remember, if you’ve come and gone, and I’m still unsatisfied, we can always go back to the good old dependable clitoral orgasm. I just know how good you’re going to get at it.

But really, honey, the point isn’t to learn a bunch of new tricks, but to learn to accommodate our changing bodies and to have a more deeply satisfying time together.

And that’s going to take some good communication and a lot of practice.

So, let’s get started. I’ll bring the lube; you get the wine and chocolate.

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You know that we always encourage you to exercise. Keeping fit is excellent for your overall health, and it keeps you sexually tuned up as well. You have more energy; you have a better self-image; you probably have less pain in your joints and elsewhere; and you probably have better range of motion.

So, far be it from us to discourage any form of exercise. But, we have a teensy qualification for those of you who like to ride bicycles.

Take care of your bottom.

Turns out that the numbness and tingling you feel after a nice, long ride is an indication that the nerves and tissue on the pelvic floor may be affected, which means less sensation in the genital area. And lord knows we don’t want to compromise anything down there.

A few years ago, researchers found that policemen who rode bikes on the job had less sensation and some erectile dysfunction. Following the study, women cyclists began to suggest that this wasn’t just a guy thing.

Sure enough. A new study of female bike riders by researchers at Yale University confirms that women who ride at least 10 miles a week also lose sensation on their pelvic floor. This effect was particularly striking for women whose handlebars were lower than their seats and was even greater when riders lean forward onto the dropbars for a more aerodynamic effect. These positions put the most pressure on the perineum. “That part of the body was never meant to bear pressure,” Dr. Steven Schrader, lead researcher for the study on male riders. “Within a few minutes the blood oxygen levels go down by 80 percent.”

Granted, these gals were competitive bikers, so a maximal aerodynamic position isn’t likely to be your overriding concern, but if you tend to lean forward as you ride, or if you feel numbness, pain, or tingling in your pelvic floor, you should raise your handlebars to a more upright, granny-style position. This helps to distribute pressure to the anatomical part that’s meant to take it—your sit-bones.

And if you really, really like to ride, you could consider a no-nose bike saddle. A list of manufacturers is here. A cyclist’s discussion of the pros and cons are here.

The take-away? By all means continue with your regimen, and more power to you. With a few minor adjustments, you should be on the road and more comfortable than ever.

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Tightening of the vaginal opening is one of the effects women can experience from the loss of estrogen. The type of lubricants that offer the most “slipperiness” and the least resistance is silicone; Pink may be the most popular at MiddlesexMD in that category.

It is possible to gradually, gently, and comfortably stretch the vaginal opening by using vaginal dilators. These are available in a set of graduated sizes; start with the smallest (and plenty of lubricant) in daily exercises and, when comfortable, progress to the next-larger size.

Only rarely is surgical modification appropriate for addressing this condition. With patience, women can typically achieve comfort with dilators and lubricants.

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Dear beloved partner of mine:

We’ve been together for a long time. We’ve weathered some storms; we’ve had our ups and downs. The kids are raised; the house is ours again. These should be our golden years, right?

That’s why we need to talk. (I saw you cringe.)

You don’t like to admit it, but things are changing for me. Yes, it’s the change. The hot-flash and mood-swing change. The big M.

Maybe you’ve noticed that I don’t lubricate as well during sex and that it takes me longer to become aroused. In fact, maybe you’ve noticed that I’m not “in the mood” much, or rather, I’m in a lot of moods, not all of them pleasant. That’s because my emotions are on a trapeze, my body’s changing, and so is the way I feel about sex and the way it feels to me.

And because I want our sex life to be fabulous in our golden years (I’ve read that after menopause, sex is often better than ever), I want to share some of the stuff I’ve learned. This may require some adjustment on your part, but in the interest of a happy, satisfied, sexy wife, it’s worth it. Right?

Let’s start with a little quote from a friend, influenced, I think, by Shakespeare:  “Tup my mind and you can tup me.”

There’s a deep truth in that colorful nugget. Sex begins in our minds long before our bodies kick in. If you want good sex, here are some ways to get my mind in the game:

  • Make me feel valued, desirable, beautiful. Maybe I’ve gained a few pounds; maybe I’m drenched in sweat at night; maybe I’m feeling old. But yours is the only opinion that matters to me. Look at me the way you used to. Bring me flowers. Tell me I’m beautiful—and mean it.
  • Listen to me. Turn off the TV. Don’t offer solutions. Don’t try to fix things. Validate what I’m going through. Don’t patronize me or belittle my experience. And don’t even begin to think that it’s “all in my mind.” This is just a rough patch, and frankly, how sexy I’ll feel toward you on the other end will have a lot to do with how attentive you are now.
  • So—be attentive, just to be supportive, not for sex. Make dinner or clean up afterward. Leave a love note on the dresser or a sexy text on my cell. Do small things that let me know you’re thinking of me. And not once or twice. Make this the new normal.
  • Work out with me. I’m not happy with the way my body’s changing. I don’t feel sexy, and I don’t feel confident. You can help by not only encouraging me to exercise and eat healthfully, but also by doing it with me. If we both diet and get in shape, think how much better sex will be—and maybe how much longer we’ll have to enjoy it!
  • Touch me. Just loving, compassionate touch without a hint of horniness. You know I’m a sucker for a good snuggle. You don’t? Well, it’s time you learned. A quick hug; a little shoulder massage after work; a nighttime cuddle—just to let me know you care.
  • Be patient. You may be a magnet for my moods, and not the mood you’re hoping for. Try to understand that my hormones have run amuck and that my body’s playing tricks on me, and that you (certainly not my boss or my mother) are the safest target. I don’t like it, either. Give me some space. Don’t take it personally. If I was once a nice person, she’ll be back, and she’ll be very grateful for such a thoughtful, supportive partner.
  • Be playful. Lighten up. Make me laugh. You don’t have to be seriously funny, just be a little goofy. Laughter releases all kinds of soothing juju, and it reminds us that life is good.
  • Educate yourself. Read this blog and the MiddlesexMD website so you have some idea about what’s going on with my sexual apparatus. Then you can be on board when I suggest trying lubricants or sex toys.

With your support, I’m going to come out of this stronger, sexier, and more sure of myself than ever. We’re in this together, Honey, whether you like it or not.

As one gynecologist said, “The key to a woman successfully going through menopause is the quality of the support she gets from her husband, or the man in her life. The major mistake a woman makes is to think it’s her problem, because she doesn’t want to stress [her partner] out. There is no such thing as an uninvolved partner.”

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If you’re experiencing some irritation with clitoral stimulation, you might start with a hybrid (Liquid Silk or Sliquid Organics) or a silicone lubricant (Pink, Pjur, or JO). They provide more slipperiness for longer than their water-based counterparts.

And I would recommend that you try a vibrator. You can vary the intensity of the vibration, the pattern of vibration (continuous or pulsed, for example), and the pressure you (or your partner) apply–all helpful to finding what you need *now* for arousal. I’d recommend the Lily or the Siri as two external options that are versatile, have nice soft surfaces, and can be recharged. The Kiri is a battery-operated, waterproof option with similar features.

Finally, if you’re using a localized hormone like Premarin internally, with an applicator, there may be no added benefit from using a vaginal moisturizer. There’s no harm in trying it, though, and I encourage moisturizer use among women who are not using localized hormones. If you choose to, Yes is the preferred product for many women who come to MiddlesexMD.

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If one-third of women don’t fantasize and rarely feel sexual desire, does that mean they’re all sexually dysfunctional? (Actually, the term is “hypoactive sexual desire disorder.”)

Or does it mean that the medical community needs a better understanding of how women get turned on, why we want to have sex, and why we might not want to have sex?

The research is clear and consistent: A lot of us simply don’t feel much sexual desire. We don’t think about sex much “in between,” and we aren’t particularly motivated to initiate sex. We do, however, enjoy it once the ball gets rolling, and we feel pretty good about our sex lives overall. “Research confirms that women report sexually satisfying lives despite rarely or never sensing desire,” writes Dr. Rosemary Basson in an editorial in Menopause: the Journal of the North American Menopause Society.

Basson is a champion for less labeling and a more open-minded understanding of female sexual arousal and response. (That’s why we love Rosemary!) She and others hypothesize that women have a different arousal mechanism than men, less straightforward and linear, more subtle and complex. Maybe desire and arousal overlap and reinforce each other in women. Maybe we need to light the kindling—a little nibble on the earlobe, a little stroke along the thigh—before desire and arousal begin to smolder. And sometimes life experiences affect our sexual appetite and responses. Longstanding personal issues, like childhood abuse or problems with our partner, for example, or recent developments, such as illness or depression.

Basson advocates careful consideration of all the variables when it comes to labeling one-third of women as sexually dysfunctional because sexual desire in women is subtle and many-faceted. Is a physical illness the impediment, or is it the financial worry that accompanies the illness? Or is it depression brought on by the medication for the illness?

Basson encourages a more “detailed, careful interview” to establish causation. And she is hesitant about blaming hormonal or neurochemical imbalances, which she says there is lack of evidence for.

When women are carefully examined, she feels that only a “theoretical sub-fraction… would merit a diagnosis of intrinsic sexual disorder.”

The bottom line, ladies? Lots of us don’t think about sex much in the course of daily life, but light the match, and we warm up nicely. For most of us, this isn’t a problem. So why consider it a sexual disorder?

And if it is a problem in our relationship, try to find a medical professional who’s willing to perform  the kind of “detailed, careful” examination that Basson recommends.

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In our little roundup of sexually transmitted infections, maybe you’ve noticed that many of them have no symptoms, and others mimic common illnesses like the flu or a urinary tract infection.

The take-away? There’s no way to know if you’re carrying an STI without getting tested. And there’s no way to prevent reinfection unless your partner gets tested, too.

Viral Infections

That said, here’s an overview of the most common viral sexually transmitted diseases. That’s right, they’re caused by viruses, and you know what that means. You may well be stuck with this bug and at risk of infecting others for the rest of your life.

Here’s the list of bad boys:

Herpes Simplex Virus (HSV)

How common is it?

Very. One in five women has genital herpes. There are two types: Type 1 is the oral virus that causes cold sores. Type 2 infects the genital area. But the oral virus can infect the genitals and vice versa.

How do you catch it?

Through genital contact or oral-genital contact. The affected area can be contagious even when the lesions have healed. Condoms can help reduce infection, but it may not cover all the affected areas.

What are the symptoms?

The first outbreak is the worst and usually occurs within two weeks of infection. It may be accompanied by flu-like symptoms as well as pain and burning in the area of the lesions. But many people hardly notice the infection. Several less severe episodes may occur in the first year, then with lessening frequency and severity after that.

As with other STIs, herpes compromises the immune system, making the person more susceptible to new infections.

Human Papillomavirus (HPV)

How common is it?

HPV is the most common viral STI in the U.S. today. There are many strains of HPV and about half of sexually active people have one or more of them.

How do you catch it?

Through genital contact during sex, even though the carrier may not have symptoms. It can also be passed through genital-oral contact. A person can carry—and pass on—the virus for years without knowing he or she has it. A person may also be infected with more than one strain of HPV. Latex condoms offer some protection, but the infected skin may not be covered by a condom. “To be most effective, they [condoms] should be worn with every sex act, from start to finish,” according to the CDC.

What are the symptoms?

HPV is usually asymptomatic, and about 90 percent of infections spontaneously clear up after a year or two, but for those that don’t some strains of HPV cause genital warts and others cause cervical cancer.

Genital warts (considered a low-risk virus) may be small bumps of various shapes and sizes on the genital area that appear weeks or months after infection, even if the partner doesn’t know he or she is a carrier. They may go away, become smaller, or grow, but they don’t become cancerous.

Cervical cancer (considered high-risk) has no symptoms until it is advanced. Abnormal cells are usually found in a Pap test; that’s why regular screening is important to determine whether the virus is high-risk.

Vaccines are available against several strains of HPV


How common is it?

One million people have HIV/AIDS in the U.S., according to the National Institute of Allergy and Infectious Diseases. About 20 percent don’t know they’re infected. About 50,000 new cases are diagnosed every year.

How do you catch it?

Through contact with vaginal fluid, sperm, blood, and breast milk of an infected person. The virus is most contagious shortly after a person is infected, but it takes from 3 to 6 months for an accurate diagnosis of infection. Before that, tests results can yield false negatives.

People who have another STI are up to five times more likely to contract HIV/AIDS. People who have HIV/AIDS plus another STI spread the disease more effectively.  For example, levels of the HIV virus are 10 times higher in men with gonorrhea. This is why it’s critically important to be tested and treated for other STIs. It’s also critically important to use latex condoms with a sex partner until you’ve both been tested and are sure enough time has passed for the test to be accurate.

What are the symptoms?

There may be no symptoms at first or the infected person may experience and intense flulike episode within a month of infection. The “flu” goes away; the system begins to produce antibodies to fight the infection, and the disease appears dormant.

Eventually, however, after several years, the compromised immune system collapses, and full-blown AIDS develops. Other infections take hold—pneumonia, diarrhea, and the telltale lesions of Kaposi’s sarcoma.

Medical science has progressed to the point that, with daily medication and close monitoring, a person can live with HIV for many years without the disease progressing to AIDS.

So, there you have it. But before you join a convent, remember how nice sex is, and especially with a special someone. Chances are, you both are infection-free. But why take chances when the stakes are so high and prevention is relatively easy?

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