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Archive for the ‘Questions…and answers’ Category

Let’s first acknowledge that women—and men, too—come to sex with a host of different backgrounds, value sets, cultural expectations, emotional foundations, and experiences. It’s very difficult, given that variety, to assert that anything is or should be true for every woman.

It is theoretically possible to have a strong physical attraction and enjoy sex with little emotional intimacy involved—whether we are men or women. There are differences between us, though: Research suggests that for women there are six neurotransmitters involved in sexual activity, and that the areas that “light up” in our brains with sex are completely different from men’s responses. Women release oxytocin with sex, a very strong bonding hormone; men don’t.

Cultural stereotypes may exaggerate the differences between men and women when it comes to sex, but the science is there to prove there are differences.

Among the women in my practice and in the rest of life, I observe that women often go into sexual experiences with an expected outcome that includes some emotional connection. Most of the women I see desire emotional intimacy as a cornerstone for their enjoyment of physical intimacy. And the study I recall that went the furthest in qualifying sexual enjoyment (“A Portrait of Great Sex“) implied emotional intimacy as intertwined with physical intimacy.

All of that said, I come back to the fact that women come to sex with enormous variety of experience and expectation. As long as she is caring for her own emotional and physical safety and health, each woman can choose, I hope, the right combination of emotional and physical intimacy.

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What you ask about specifically is your clitoris, which, along with other genital tissues, does typically shrink with the loss of estrogen—whether through menopause or some other medical event. Because you’re under 40, which is young for what you’re describing, I’d encourage you to express your concern to your health care provider and have a thorough pelvic exam. The exam will be helpful in finding out whether there’s another vulvar condition causing the tissue changes—or whether you’re experiencing normal changes.

As we lose estrogen, we do face something of a “use it or lose it” proposition. That is, circulation and stimulation keep our genital tissues healthier; left to their own devices, they’ll atrophy. If you don’t have a partner right now, a vibrator is a great choice to provide stimulation and increased blood supply to the area. Maintaining your health means you’ll be ready for intimacy when—just when you least expect it—a relationship emerges!

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I wish there were a “secret sauce” that worked for all of us to restore libido. Not surprisingly, it’s more complicated than that.

It’s somewhat unusual to have an abrupt change to libido; for most women, it’s a “slow drift.” The first thing to consider with a dramatic change is any new or different medications. There are quite a few that have effects on desire: blood pressure, pain, and mood medications (antidepressants) to name a few. If you have had a change, you can work with your doctor to experiment with dosage or medications; let him or her know of this unintended side effect.

You ask about Cialis and similar products. They can help with orgasm (as they do for men), by arousing blood supply to the genitals, but they don’t have an effect on libido or desire.

One option to consider is testosterone. While it’s thought of as a male hormone, it’s also present in women and is linked to libido. Some physicians aren’t willing to prescribe it for women because it’s an “off-label” use, but 60 percent of women report significant improvement in libido with testosterone replacement, and 20 percent of U.S. prescriptions for testosterone are now for women.

The other factor important to consider is mindfulness–which we might also call intentionality. While you may not feel desire that motivates you to be sexual right now, you know your long-time partner does. You can make the decision (together) that you will continue this activity together, including foreplay. (And I note a recent study that linked frequency of sexual activity with the quality of relationships, which confirmed my intuition.) When you make that decision, sex is a “mindful” activity: You anticipate and plan it and prepare physically and emotionally for an optimal experience with your partner.

Many women grieve the loss of a part of their lives that was once so important and fulfilling. It’s most often an unnecessary loss, and staying sexually active has many health benefits as well as giving us feelings of both individual wholeness and connection to our partners.

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You may be among the 4 percent who won’t experience orgasm–who, for some reason, simply can’t, under any circumstances. It’s more likely that you’re among the 96 percent who can. When a woman tells me she’s not sure if she’s experienced orgasm, I say she probably hasn’t; it’s fairly obvious when it happens.

Most women need direct clitoral stimulation to reach orgasm; what we see so often in movies, of partners climaxing together through intercourse alone, is rare in real life. Beyond that, there’s plenty of variation: Some women may need an hour of clitoral stimulation; others may experience orgasm through brief nipple stimulation.

I recommend that each woman know her own clitoris, because degrees and types of pleasurable stimulation vary among us. Vibrators are very effective in stimulating the clitoris, and spending time yourself, exploring in a relaxed environment, will help you advise your partner on what feels good. Soothing or arousing music or a sexy scene from a movie can help, too.

When you’re ready to go further, you can try internal stimulation, which leads to orgasm for about 30 percent of us. A vibrator like the Gigi2 can be used both externally and internally, so you can place it in the vagina (use a lubricant to be sure you’re comfortable) and see what happens.

While chances are good (about 96 percent good!), there’s no guarantee of orgasm. And because being focused only on orgasm can actually inhibit your ability to experience it, I hope you’ll enjoy the intimacy and other sensations along the way!

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The loss of estrogen that comes with menopause results in thinning of urogenital tissues, which include the vagina, vulva, and urethra. Because those tissues are thinner, they can be more fragile and susceptible to “trauma.” We don’t think of sex as “traumatic,” but the activity can cause minor tissue damage.

Sex can also introduce bacteria to the bladder via the urethra, which can lead to bladder infections. And either an infection or the inflammation of damaged tissue can lead to the symptom of urinary urgency.

Using a lubricant during intimacy will minimize the “trauma” to tissues. Emptying the bladder soon after sex may flush out bacteria before they can proliferate and become an infection. (Women with frequent urinary tract infections linked to sex sometimes find it helpful to take a dose of oral antibiotic with sexual activity.) And a therapy like localized estrogen or Osphena may help by restoring proper pH and increasing cell layers.

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First, let me assure you that you’re not alone in feeling a loss of libido: It’s common for women to lose desire, even in great, emotionally supportive relationships.

Low desire is challenging to treat, because we women are complex sexual creatures. I prescribe testosterone for some of the women in my practice; about 60 percent of those who’ve tried it have found that it does boost libido. I wish it were 100 percent, but it’s not! And some physicians are reluctant to prescribe testosterone for women because it’s “off-label.”

Given what we know about women’s sexuality, I advise women to engage “mindfulness” when it comes to sex. Often, we feel desire somewhere in the process of being intimate; we may not be driven to intimacy by desire. We need to choose to be sexual! I encourage women to plan for sex, committing to a frequency that is comfortable for both partners. It might be once a week, once a month, on Friday evening or Sunday morning—whenever you’re least likely to be distracted, stressed, or tired. When we have been sexual, we’ve typically found it pleasurable and we’re glad we did!

Finally, you mention being self-conscious about your breasts, which are no longer like they used to be. We are our own worst enemies when it comes to body image, and we pay the price when we rob ourselves of pleasures! I’ll bet your partner doesn’t look like he used too, either, and that he loves every inch of your body, as you love his. You might reread this blog post on body image and try some of the suggestions to “send your body some luv.”

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What you describe—pain and a burning sensation around your clitoris—is most consistent with vulvovaginal atrophy. As we lose estrogen, the genital tissues thin, and the labia and clitoris actually become smaller. There’s also less blood supply to the genitals. Beyond making arousal and orgasm more difficult to achieve, these changes can also lead to discomfort, and experiencing pain when you’re looking for pleasure will certainly affect your sex drive and arousal!

Localized estrogen is the option that works best (and it’s often a huge difference) for most of my patients, restoring tissues and comfort. Talk to your health care provider about the available options and what you might consider in choosing one.

A vaginal moisturizer can also help you restore those tissues, but I suspect you’ll find that most effective in combination with localized estrogen.

Please do take steps to address your symptoms! If sex can be more comfortable and enjoyable for you, I’m hopeful that your sex drive will rebound.

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You say that you’re both excited and anxious about being with your partner, but that you’re tense with him and haven’t experienced this before. Let me first say that there’s no magic pill that will solve this problem.

For women, sharing sexual intimacy requires the ultimate in trusting, giving, and sharing. This emotional component is just one part of a complex whole for women, but it’s the place I’d start. I’m curious about whether you’re tense with this partner in situations outside the bedroom, and whether you’ve been able to express your concern. It would be helpful it it’s a problem you’re looking to solve together rather than a “performance anxiety” issue for you alone. Being anxious about being able to experience orgasm only makes it more difficult!

You might consider seeing a therapist with a focus in sexuality to be sure that you’re clear on the emotions and feelings you’re experiencing.

If there is no emotional barrier to address, I’ve recommended Viagra or a very low dose of testosterone for women who have lost orgasm or intensity; both of these drugs are prescribed “off label,” which means they’re FDA-approved for another use.

I wonder whether you’re able to experience orgasm with self-stimulation; if you haven’t tried, I encourage you to. A vibrator used either alone or with your partner may provide the increased sensation you need. And if you’re able to orgasm alone, you may learn some things about your response that you could share with your partner.

Sex is often complicated, with multiple interdependent components; it doesn’t help that our bodies change as we gain years! Please do look to a therapist for any emotional considerations; if physical considerations remain, a health care provider knowledgeable about menopause can help you evaluate options. Most women in my practice are able to reclaim this part of their pleasure!

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I rarely recommend water pills unless a patient is in heart failure and we need to decrease the fluid load on her heart and kidneys.

Bloating is usually related to gastrointestinal issues, and water pills don’t address those issues. When the kidneys are functioning properly, they’re getting rid of excess fluid; water pills put you at risk for depleting needed fluid or becoming dehydrated. Better options are to reduce salt intake and (counter-intuitively) to drink water.

My take on water pills for weight loss is the same: It’s not a safe long-term solution.

What do I recommend? So sorry, but there’s no magic! Eat well, exercise often, and see your health care practitioner to diagnose and find healthy and long-term ways to address symptoms!

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The best option for what you describe is a regular routine of vaginal moisturizer use; use it consistently at least two times a week. Add a lubricant at the time of intercourse to assure your comfort.

Yes is the most popular product at MiddlesexMD for this condition; it’s an organic vaginal moisturizer that can also be used as a lubricant. Emerita is another moisturizer option that works well.

Lubricants come in a number of formulations, so you might want to use our personal selection kit to try out a few and find the one that’s most effective for you and your partner.

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