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Archive for June, 2012

Even if you’ve been an emotional Rock of Gibraltar throughout your life, menopause can brew up a perfect storm for jittery moods, anxiety, and depression. And in addition to its psychological punch, depression and anxiety can put a definite crimp in your sex life.

According to the North American Menopause Society, “Women suffering from depression (which is associated with a chemical imbalance in the brain) report symptoms of prolonged tiredness, loss of interest in normal activities [like sex], weight loss, sadness, or irritability.”

Who feels like sex when the rest of you feels like this?

Menopause and depression make such cozy bedfellows because

  1. hormonal and endocrine-related turmoil are the very hallmarks of menopause, and they are intimately related to our moods. And
  2. certain predictable but challenging life events tend to coalesce during this period.

Ever since puberty, you’ve made a sometimes uneasy peace with the normal hormonal fluctuation of your monthly cycle. But now your hormones are all over the map. And in this case, a hormone like estrogen affects the functioning of a whole lot of other stuff.

For example, estrogen affects serotonin levels in your brain, and serotonin is the happy juice that regulates sleep, mood, energy, and libido. “It’s central to our well-being,” writes Colett Dowling, psychotherapist and author of The Cinderella Complex in an article on her website.

Dowling is no stranger to the emotional and physical punch of those hormonal changes. “It was only when I was a year past menopause that I began to address the sleep problems I was having, as well as the loss of energy and libido.… It took far longer than it should have for me to learn that menopausal depression, related to a drop in estrogen, was causing my symptoms, and to get the treatment that put me back on track.… I was stuck in this pattern for many many months, and it became hard not to think: Is this it, the end of my vitality and productivity?”

Research also suggests that women with depressive bouts in the past or who suffer from more severe or prolonged hot flashes are also more susceptible to depression during menopause.

And don’t count on life giving you a break during this stormy period. You may have to adjust to your children leaving, maybe to the death or disability of a parent, maybe to health issues of your own or of your partner. You may struggle with the emotional transition of a changing self-image or the inevitable and final loss of youth. Cultural stereotypes being what they are, you have to make peace (or not) with different social roles and perceptions.

Given these hormonal and psychological transitions, is it any wonder that depression often dogs the menopausal years? Is it any surprise that our sex life is an early casualty?

To get a handle on this dance between depression and loss of libido, begin by understanding how common and treatable it is. Give yourself a break and don’t be embarrassed to ask for help. Dowling writes, “Women at mid-life often feel guilty about their mood changes and avoid seeking treatment. ‘This will pass,’ they think, and while that may be true, depression can seriously affect the quality of life, including one’s ability to make a living.”

Loss of libido is another of those quality-of-life issues. It can strain a relationship and affect your sense of well-being. You don’t have to compromise either your happiness or your sex life. And you shouldn’t suffer in silence.

A few additional issues with regard to depression and libido:

  • Antidepressants that affect serotonin levels (SSRIs and norepinephrine reuptake inhibitors) also affect libido, and not in a good way. If you’re on an antidepressant and have lost any interest in sex, talk to your doctor about a change in medication.
  • Low thyroid function (hypothyroidism) looks a lot like depression. It might be beneficial to have your thyroid levels checked. Also check your iron levels for anemia.
  • Consider whether unresolved relationship issues might be involved with your lack of interest in sex. Many doctors think a multi-pronged approach to depression and loss of libido is a more effective treatment. This may involve antidepressants as well as psychological counseling and perhaps lifestyle changes.
  • Ask your doctor about trying testosterone therapy to boost your sex drive. The jury’s still out, but there’s some indication that it can be effective.
  • Don’t overlook the basics. Your salad years of hopping in the sack for a quickie in the afternoon may be over, but you can still enjoy long, slow evenings of sweet intimacy. Just don’t forget the lube—and maybe a few pillows to keep things comfy.

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First of all, know you’re not alone. By some estimates, as many as one in ten of us has never experienced orgasm, and among those of us who have, it happens in only about half of our sexual encounters. I’m not suggesting that makes it okay that you’re struggling; knowing the facts, though, can lessen your stress about what’s happening—or not happening.

In spite of what you see in the movies, most women—up to 80 percent—cannot have an orgasm with intercourse alone. Most women need direct stimulation of the clitoris, and the mechanics of intercourse just don’t provide that. Oral or manual stimulation of the clitoris tends to lead to orgasm, and vibrators give the kind of stimulation needed—as variety or because it’s easier. Especially as we grow older, many women need the extra stimulation a vibrator provides.

Vibrators can be for external or internal use. External vibrators (Siri, Lily, Kiri, and Isis) work extremely well for women who respond to direct clitoral stimulation. Other women like the internal stimulation of the vagina and G spot, too, for which some vibrators (Gigi, Raya, Celesse) are designed for insertion. Those vibrators can also be used externally on the clitoris. If you want the extra stimulation during intercourse, the external type will work best.

There are additional features you might think about, too; I’ve written whole blog posts on the topic. Whatever you might choose (and our most popular are the Siri and Gigi), I often recommend to women that they try self-stimulation to see what kind of touch where feels best. That, too, lessens the pressure when you’re with your partner.

Enjoy the exploration! It’s never too late to learn even more about your body.

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A woman I know was sitting in a café with her lover. Newly single after having been married for many years to her first and only sexual partner, she was babe in the sexual wilderness. She didn’t know the customs, the language, the expectations, or even how to protect herself.

She’d grown up in a very straightlaced family, so the sexual revolution had completely passed her by. Sex with her husband had been routine and boring, but she wasn’t assertive enough to try to spice things up. Now this dashing bachelor was suggesting positions she’d never tried, and trying things she’d never thought of. She only hoped her rank inexperience wasn’t too obvious.

Their eyes met over the coffee cups. He cleared his throat. “Have you, um, had much practice sexually?” he asked. “You’re pretty tight in bed.”

“I thought I was going to throw up,” my friend said.

Whether you are in a long-term relationship or newly unattached, you aren’t alone in feeling sexually insecure and inexperienced. Many of us came of age before casual sex was commonplace, and many more of us married young and maybe didn’t get the practice our peers seemed to enjoy. And others of us decided that sex wasn’t meant to be casual, and we deliberately limited our opportunities.

Besides, don’t we tend to assume that everyone else is somehow better—more sophisticated and experienced? Or that we aren’t quite up to snuff? And isn’t the whole realm of sex with all its juicy nakedness and vulnerability a particularly handy target for our free-floating insecurities? In fact, is there anything more acutely capable of making us feel inept?

I’m betting that in a situation like my friend’s a lot of us would feel pretty inept.

Given that most of us are probably a little rusty on our Kama Sutra positions, and that many of us will find ourselves with new partners at some point in our lives, how might we approach that uncomfortable feeling of sexual naiveté—the feeling that we never really acquired this oh-so-adult skill

First, get a grip. We’re mature, self-evolved women who’ve accumulated skills and talents over the course of a lifetime. So what if sex wasn’t one of them. That’s no reflection on our self-worth. And it’s never too late to learn.

We also face tremendous social pressure and non-stop cultural messaging that lets us know that everyone is having lots of sex and performing feats of skill and derring-do in the bedroom.

That’s a lot of nonsense. A lot of single people aren’t “doing it,” and a lot of others aren’t having such a blast between the sheets. And besides—we aren’t everyone, as our mothers used to say. We should not be bullied into insecurity or rash action by what we see on “Desperate Housewives.”

We need to protect ourselves emotionally and physically, and we need to see ourselves as confident, sexual, and desirable.

A person with confidence and self-worth doesn’t need to prove anything in the bedroom because sex in a mature, caring relationship is about more than skill, experience, and acrobatics. In such a relationship, we should be able to talk about sex and what we’d like it to be for each other and how we can make it better. Then maybe sex can take its appropriate place as another level of sharing and a different way to express love.

Let’s not sell ourselves short or buy into the media messaging. It’s easy to learn a bunch of fancy sexual moves. What’s hard is to find the right relationship to have sex in.

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I often recommend that people try the North American Menopause Society’s (NAMS) website. NAMS has a rigorous process for certification, so the health care providers who are a part of it are likely to be committed to continuing sexual health for women like us. The website has a practitioner finder, too, so you can see whether there’s a member in your area.

If that option isn’t fruitful, we recently published a longer blog post with some other suggestions to explore.

Good luck, and keep looking! It’s important to have a health care provider you’re able to communicate and work with as you navigate the years ahead.

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About one in five women smoke. If you’re part of that 20 percent, I’m sure you’ve heard all the warnings and finger-wagging about the health hazards of smoking. Maybe you’re tired of hearing about all that bad stuff.

Well, unfortunately, here’s more bad news.

Just view this post as informed consent rather than yet another attempt to scare the bejeesus out of you. You can ignore it—just don’t say we didn’t tell you.

Several recent studies on smoking and menopause have found that not only do smokers enter menopause early by about a year or two, but also that menopausal symptoms, such as hot flashes, are more intense.

The more you smoke, the greater your chances of early-onset menopause. (Your odds are more than double, according to a 2007 study of 2,000 women in Oslo, Norway.) Researchers think that smoking may affect hormonal levels or the secretion of enzymes related to hormones. It may also activate certain genes that trigger the onset of menopause.

Early menopause is troubling because it’s linked to heart disease and osteoporosis. In fact, a team of researchers in Boston have hypothesized that smoking rather than early menopause may be to blame for the rise in heart disease they see in post-menopausal women.

In addition to entering menopause early, women who smoke have more severe menopausal symptoms, and now a group of researchers from the University of Pennsylvania have specifically linked the severity and frequency of hot flashes to smoking and to genetic variations that control the metabolism of estrogen and the body’s response to environmental toxins.

In a 10-year study of 300 women, half of whom were African-American, smokers overall were about twice as likely to suffer from more severe and frequent hot flashes than nonsmokers. But with certain genetic predispositions, the African-American smokers were 84 percent more likely to suffer from intense and frequent hot flashes, while the white smokers were 56 percent more likely.

In an article for WebMD Health News, Dr. Margery Gass, executive director of the North American Menopause Society said, “I don’t think most women who smoke know that they are at risk for earlier menopause and more severe menopause symptoms.”

But now you know.

So if you suffer from hot flashes, and you smoke, you have one more reason to consider quitting.

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One of the advantages of having a medical advisor team is that I can hear reports from events I can’t attend! Michael Krychman, part of the team and medical director of The Sexual Medicine Center at Hoag Hospital and the Executive Director of the Southern California Center for Sexual Health and Survivorship, provides this update from a May meeting.

A resurgence of interest in female sexuality was apparent last month at the American Congress of Obstetricians and Gynecologists’ annual meeting. I had three presentations on female sexuality; menopausal sexual health and vaginal dryness were topics throughout the plenary and clinical courses. I completed a post-graduate course with Dr. Haywood Brown, Chair of Duke University, on Sexuality through the Lifecycle, which addressed topics like sexuality and pregnancy and postpartum; chronic medical illness and sexual function, including breast cancer; lesbian sexuality; and treatment paradigms for dysfunction. A brief, informative lecture on everything you always wanted to know about male sexuality for the female health care provider was also included in the core curriculum.

A sold-out luncheon session focused on emerging sexual pharmacology. Among the topics were new data about Flibanserin [which we’ve talked about before as “pink Viagra”]; intravaginal DHEA ovules, which may help with vaginal atrophy; PT141/bremelanotide as an option for arousal issues; and new lower-dose intravaginal estradiol for localized hormone treatment. There was also significant discussion about Osphena, which may be the first oral medication for vaginal atrophy.

A clinical seminar on Elderly Sexuality had over 100 attendees, who were very interested in learning about prevalence and incidence of sexual issues as women age; a comprehensive treatment paradigm was also presented. There were several updates on vaginal dryness and testosterone, too.

Even in the exhibit hall, sex was evident! Lelo, a premier self-stimulator company, was swamped with visitors during all hours. They introduced Intimina, their new sexual wellness line of products [which includes the Kiri, Raya, and Celesse vibrators].  Semprae Laboratories, makers of Zestra essential arousal oil, was swamped with interest over their new in-office physician retail program and distributed thousands of samples. The L’il Drugstore booth was busy with moisturizer Replens. Neogyn, a new vulvar soothing cream, was also on the exhibit floor. I even saw the Journal of Sexual Medicine floating around!

Medical support for women’s sexuality has faced some challenges in the last few years. The FDA hearing on Flibanserin and the disappointing efficacy results of Libigel were a few recent set-backs, but in spite of them, attention to female sexual function and treatments for dysfunction looks to me to be going strong.

It is definitely an exciting and interesting time. The field of female sexual health and wellness is alive and thriving.

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You say you were diagnosed five years ago with fibroids, and you’ve reached menopause (one year without periods) quite recently. The good news is that fibroids tend to shrink in menopause, so they’re unlikely to be causing the soreness you describe after deep intercourse.

The less good news is that your symptoms sound most consistent with vaginal atrophy, the typical consequence of the absence of estrogen in the vagina. I’d recommend that you start using a vaginal moisturizer or vaginal estrogen as soon as possible. The moisturizers are readily available; you’ll need a prescription for the estrogen, which comes in a variety of forms for local application.

What you’re experiencing is normal and easily treated—more good news!

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