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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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There are many benefits to being sexually active: It releases estrogen and increases oxytocin, serotonin, endorphins, and immunoglobulin A. This chemical and hormonal stew makes us both feel and be healthier. Having sex makes us feel powerful, giving, and connected, all of which feed our relationships with our partners.

I came across a recent study that affirms another benefit I often talk to women about: Sex is good exercise.

The study was conducted by Antony D. Karelis, who teaches exercise science at the University of Quebec at Montreal. Participants in the study wore armbands while having sex, and also jogged on treadmills to produce comparative data. The results? On the “metabolic equivalent of task” scale, on which sitting still ranks a 1-MET, sex ranked 6-MET for men and 5.6-MET for women. That puts it, according to Gretchen Reynolds, author of “Sex as Exercise: What are the Benefits?” as roughly equivalent to playing doubles tennis or walking uphill. To do your own comparisons, it’s categorized as “moderate exercise.”

Good to know, right? And I think we midlife women can use this knowledge to our advantage. Part of my counsel to women experiencing diminishing libido is to be intentional about remaining sexually active. There are two parts to my rationale: First, as our hormones diminish, we’ve got that “use it or lose it” thing going on that I’ve talked about before. Second, having sex begets having sex. That is, we women will want to have sex more often when we—wait for it—have sex.

There’s a line from the study conclusions that made me smile: “Both men and women reported that sexual activity was… highly enjoyable and more appreciated than the 30-minute exercise session on the treadmill.” I’m so glad to hear that!

So I start to wonder: How can we apply to our sex lives the same thinking that gets us religiously to yoga or Pilates several times a week? Neither we nor our partners want us to be thinking about sex as one more chore on the to-do list or an obligation on our calendars. But can we consider it a gift to ourselves and our health, as we do our morning walk or Zumba class? Will that give us the extra incentive to make the time and the commitment?

I’m hoping so.

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A New Breakfast of Champions

It all began when entrepreneur Peter Ehrlich took a stroll through a vegan food fair in Toronto. If your livelihood depends on generating ideas, I guess that part of your brain never sleeps.

Suddenly, he realized that there was healthy, organic, non-GMO food for all kinds of health—except for sexual health.

This was Ehrlich’s Eureka! moment. Everybody eats cereal, he reasoned. Everybody wants to be sexy, and everyone wants to be healthy. Let’s bring it all together in one slick package.

Thus was Sexcereal conceived. After conception, the road to market dominance was easy. Ehrlich hired a “team of nutritionists and quality control experts” to create two recipes: one for “HIM” and another for “HER.” A very important step, apparently, was the packaging: a 300-gram bag of cereal with vintage, slightly come-hither, and very healthy-looking images of a guy and a girl. (The size of the guy’s spoon has gotten a lot of quips in the media.)

Besides a generous portion of rolled oats for both genders, which gives the cereal a granola-y look (Don’t call it granola, however; Ehrlich doesn’t like that.), the cereal “for him” has chia seeds, blueberries, black sesame and pumpkin seeds, cocoa nibs, bee pollen, goji berries, and maca powder. “She,” on the other hand, is indulged with wheat germ, soy protein, ginger, cranberries, almonds and flax seeds.

Sounds good, doesn’t it?

Sexcereal is described as a nutritious and tasty whole food with lots of fiber, iron, energy, and Omegas 3 and 6. It’s supposed to boost testosterone and promote hormone balance. Certainly, its makers want to be taken seriously as having created a good product.

But it costs $10 for that 300-gram packet, and it’s so popular that you’ll have to wait 10 days before your mail order is even filled.

The science behind the product? Not so much, as far as I can tell. Sexcereal’s success is all about the concept, the novelty, the marketing, and the media hype. Sex sells, as we all know.

So, maybe sample a packet of Sexcereal out of curiosity or send one as a gift to that person who has everything, but don’t expect a surge of white-hot passion. No matter what they say on TV.

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It’s no wonder we’re confused. First it’s good; then it’s bad. Now it’s up to you.

Hormone replacement therapy has had more media makeovers than Liz Taylor, and it continues to grab attention here and there.

The latest, and highly credible, statement on the issue is from an international roundtable of medical experts convened by the Society for Women’s Health Research (SWHR). The purpose of this gathering of experts, which represented various specialties, such as cardiovascular disease, osteoporosis, and cancer, was to take yet another objective and rigorous look at the evidence regarding hormone replacement therapy, and to make recommendations as to its use and safety. The results of this discussion just came out in the Journal of Women’s Health.

This roundtable is a good effort to shed some objective light on the risks and benefits of an issue that’s been hotly debated for over ten years now, ever since the Women’s Health Initiative (WHI) prematurely ended its groundbreaking study of women receiving hormone therapy in 2002 because of a high incidence of breast cancer and cardiovascular complications.

The problem, however, is that hormone therapy (HT) is still the only effective, FDA-approved treatment for menopausal symptoms, such as hot flashes and vaginal changes. Recently two non-hormonal drugs were just nixed by an FDA advisory panel because they were viewed as ineffective.

Ever since the WHI results were released, the pendulum has been swinging wildly with each new medical release or research report. And while this latest SWHR roundtable really moves the chess pieces very little, it does solidly reaffirm positions held by the North American Menopause Society.

(In fact, NAMS had released its latest position statement on hormone treatment barely a month earlier.)

What the roundtable did add, however, is something I strongly advocate: Give women solid information about their treatment options and let them make informed decisions about their own health.

Their findings include:

  • In younger, postmenopausal women with menopausal symptoms, the benefits of HT outweigh the risks;
  • HT is the most effective treatment for osteoporosis and should be considered for the prevention of osteoporosis, especially among at risk women;
  • Contrary to popular misconceptions, HT for early, postmenopausal women does not increase the risk for coronary heart disease (CHD) and may even reduce it;
  • HT does not increase total mortality rates and may, in fact reduce them.

Here’s how the SWHR roundtable puts it: “It’s time to put HT back on the table so that women can discuss with their providers the option of symptom relief and possible long term health benefits.”

Amen to that.

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I never knew what it meant to prime a pump until I watched a plumber work on one at my cottage. To prime a pump means to pour a little water into its fill cap to create suction and, with luck, to pressurize the thing so it draws water rather than spurting air.

The hydraulics metaphor may be more appropriate for men, but I’m betting that some of your orgasmic pressure has leaked out over the years, too. Or, maybe it wasn’t very dependable to begin with. According to some studies, from 25 to 50 percent of women have trouble achieving orgasm.

There are, however, ways to repressurize your orgasmic system—techniques that may help get the sexual juices flowing again. It’s not magic—there is still no pink Viagra that guarantees an orgasm, given that the female sexual response cycle is a lot more complicated than a water pump.

If your orgasmic mechanism needs a little priming, here some holistic ways to repressurize.

  1. Exercise. (I heard that groan.) Good orgasms require good circulation to keep all that oxygenated blood flowing to your genitals. Aging does a number on the blood flow and nerve endings in the genital area, making them sluggish and less responsive.  Exercise helps maintain good circulation. It also keeps blood circulating nicely to the brain, which, as we’ve said, is really your biggest sex organ.
  2. Kegels. C’mon. These are easy and painless (there are tools available), and they do you a lot of good. Kegels tone and strengthen your pelvic floor muscles; those muscles keep you from leaking urine when you sneeze as well as holding your internal organs in place. Strong pelvic floor muscles also create a firm “vaginal embrace,” which is nice for your man, but also gives you a more powerful orgasm.
  3. Check your medications. Several categories of drugs are libido killers, including some antidepressants, but also some drugs that reduce cholesterol and high blood pressure. If you suspect that your meds may be messing with your sex drive, talk to your doctor.
  4. Masturbate. You need good circulation down there, right? Self-pleasuring helps. It also helps you identify what you like and how to “do it” the way you like it—so you can tell your partner.
  5. Get a vibrator and other sex toys. There are all sorts of physical reasons to use a vibrator. (See #4 above.) Toys may help you release some inhibitions and learn to play.
  6. Drink a little (not a lot.) Sharing a little pre-sex cocktail can create a cozy sense of intimacy and also help lower your inhibitions. Drinking too much is a libido-killer. Share a glass of wine in front of the fireplace and move the action to the bedroom—or keep it by the fireplace.
  7. Fantasize. Think of it as your personal romance novel. You can sleep with anyone you want and do anything you want. You’re only limited by your imagination. Fantasy helps some women “get into their heads.” Try it.
  8. Positions. If you’ve been using your vibrator, you know where your sweet spots are, and the missionary position often misses them. Try the back entry “doggie-style” position which is good for hitting the G-spot, although not so good for the clitoris, or try sitting on his lap, which is good for all kinds of things.
  9. Foreplay. If you take seriously Esther Perel’s statement that, for erotic couples, “foreplay pretty much starts at the end of the previous orgasm,” you may extrapolate that good sex arises from consciously introducing sensuality into your relationship in a sustained way. Touch. Snuggle. Sextext. Write love notes. Introduce beauty and sensuality into your life that might leach into lovemaking as well.
  10. Have sex. This cannot be repeated too often. The more you have it, the more you want it, and the better at it you become. As one happily married husband said: “Practice, practice, practice.”

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Most women have very normal sexual function without a cervix. I have seen reports that suggest an issue, but in 24 years of practice, I can’t recall a single woman who was impaired by the absence of her cervix.

There are complications that result if the cervix is left after a hysterectomy, including abnormal pap smears and continued bleeding. If there is any remaining endometrium (the membrane lining of the uterus) and you consider hormone therapy in menopause, you will need progesterone as well as estrogen. I’ve seen women less fond of progesterone than estrogen.

Whether you’re able to keep ovaries in a hysterectomy is a bigger issue to sexuality—and in fact overall health—for women. Even after menopause, the ovaries continue to produce hormones. Those hormones not only mitigate some of the effects of menopause, but they also promote bone and heart health. There are times when it’s appropriate to remove the ovaries as part of a hysterectomy, but the decision needs to be made based on each woman’s health and history.

Glad you’re thinking about your continued sexual health, and good luck with your recovery!

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In January, I was working on an article I’d been asked to provide to OBG Management magazine. They’d asked me to talk about why I offer products through my practice—which was, actually, the same motivation that led me to found MiddlesexMD: There are some simple products available that can help women remain sexually active, but it’s not always easy—or comfortable—to buy them.

As I wrote the article, I wondered how you as patients feel about products being offered through your doctors’ offices, so I asked. And a number of you responded, either on the blog or directly, with your thoughts. You were overwhelmingly positive, assuming that your relationship with your health care provider was one based on trust to begin with (and I hope we’re all that fortunate!).

OBG Management published my article, called “Vibrators, Your Practice, and Your Patients’ Sexual Health,” in their April issue. Read it if you like, and take a copy to your next doctor visit if you think it would be helpful in opening a discussion about how he or she can be more helpful to you and your sexual health!

Thanks to all of you who voiced your support or concerns. We’ll keep learning together—and stay as sexually active as we choose!

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“Concern” is a relative term. If you mean should you lose sleep, no. If you mean should you work with your health care provider for an explanation or monitoring, yes.

Pap tests (also called a Pap smear or cervical cytology screening) are used to look for changes in the cells of the cervix; abnormal cells can be identified early and treated appropriately. Pap tests provide information on both whether cells have changed and how much cells have changed, so  “abnormal” covers a range of possibilities.

The most common cause of abnormal Pap results is HPV (human papillomavirus) infection, and HPV also suggests a range: there are many types of HPV. Some lead to nothing at all, some are linked to genital warts, and some are linked to cancers of the cervix, vulva, and vagina. And, let me repeat, some lead to nothing at all.

When a Pap test returns an abnormal result, it’s typical either to monitor (repeat the Pap test in six months or a year) or to take an additional diagnostic step. A colposcopy is the most common; it sounds scary, but it’s really only a close visual exam of the cervix with a magnifying device. There are several tissue sampling procedures that take cells for additional lab examination.

About 70 percent of mildly abnormal results revert to the “normal” range at the next screening. That said, it’s important to follow your health care provider’s recommendation for a follow-up test. This is not the time to procrastinate on that office visit!

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Actually, do more than wish. Be active.

Sign this online WISH petition to add your voice to others advocating for greater attention to women’s sexual health needs. The WISH petition is sponsored by the International Society for the Study of Women’s Sexual Health (ISSWSH), which is a professional organization for those of us who work in the field of women’s sexual health.

The petition supports ISSWSH’s position that “female sexual disorders are valid conditions that warrant assessment, diagnosis and appropriate therapeutic intervention.”

But WISH is more than a petition. It’s an initiative dedicated to bringing “the medical community together with the public to recognize the importance of female sexual health, so that it is no longer considered a ‘lifestyle choice,’” according to MaryAnne McAdams, director of the WISH Initiative. The group even has a Facebook page.

As a professional in the field, I feel strongly about the need for more recognition, more acceptance, more treatment options, more research, and more pharmaceutical options for women who experience sexual dysfunction.

There are many of you. The numbers vary greatly (another area for research, perhaps?), but it is estimated that from 19 to 50 percent of “normal” women experience sexual dysfunction, according to a 2000 article in American Family Physician. Predictably, that number increases when the physician actually asks the patient about her sexual health, which many don’t. (An area for physician education, perhaps?)

As I’ve said before, I’d like companies to develop more pharmaceutical options for women, and I’d like the FDA to consider them seriously and carefully. I know that it’s easier to make a drug to treat erectile dysfunction. I’m well aware that women’s desire/arousal trajectory is complex and multi-dimensional, but the more tools we have in the bag, the more successfully we can treat women with sexual issues.

It’s easier, of course, to fall back on the old “it’s in her head” or “it’s a lifestyle choice” crutch. Thankfully, that attitude is becoming discredited and debunked, but those voices are still around.

“In the last few years, there has been a small, but very loud group who have been given the chance to speak during FDA Advisory Meetings claiming that female sexual dysfunction is a made-up condition and is not ‘real,’” says WISH’s MaryAnne. “The WISH petition may be used as a source of documentation to dispute that erroneous claim.”

As a physician who treats women’s sexual health, I’d like more attention paid to the issue by government agencies, pharmaceutical companies, and my colleagues. I’d like women’s sexual issues to be acknowledged, respected, and treated with intelligence, competence, and sensitivity. And since at some point in your life, you’ll probably experience some lack of libido, difficulty with arousal or achieving orgasm, or some pain during sex, I’m sure this is an important issue to you, too.

If it is, sign the WISH petition. We know size doesn’t always matter, but the number of voices on this topic does count!

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Did you know that the whole idea behind MiddlesexMD is based on a recipe? You could call it the MiddlesexMD formula for really juicy sex. Officially, we call it “our recipe for women’s sexual health.”

We think our recipe is so important that our entire website is organized around what we’ve identified, after a lot of thought and research, as the five necessary ingredients for a satisfying love life at midlife. You can add your flavor of whipped cream and lingerie, but if those five ingredients aren’t in place, sex just won’t work very well.

These ingredients may be surprising (knowledge? emotional intimacy?), and some are unique to our stage of life (vaginal comfort, genital sensation, pelvic tone). We try to help you understand why they’re important and to give you tools and tips for understanding what they are and for incorporating them into your life.

Here’s a tool someone at a recent conference told us about; it reaches the same destination by a different path. It’s a fun quiz put together by the Association of Reproductive Health Professionals (ARHP). Sounds like place to get blood drawn, I know, but behind that bland façade is a sexy little quiz that reinforces a lot of the thinking behind our recipe.

To start, click on your age in the circle that says, “It [sex] could be better…” The questions cover a range of life issues, from physical health to libido to emotional well-being—because, as we’ve said, sex involves all our parts, including our psyche and our emotions.

While the assessment tool is meant to be light and fun, it also delivers good advice. Be honest with your answers (who’s looking, anyway?), and you’ll get some targeted, useful information to improve your sex life. And maybe the rest of your life.

You’ll discover, for example, that about 20 percent of women (of all ages) have a hard time getting turned on, and that it’s one of the most common sexual complaints. That a woman’s sexual response is complicated and affected by things like self-image and stress. (Click on the right-side box that explains how men and women are different.) The tool reassures you that most women can’t orgasm with penis-in-vagina sex alone, but need clitoral stimulation as well.

Nothing earth-shaking, but some nice reinforcement and some good tips. Take the quiz. Read the results, then dig around in MiddlesexMD for more in-depth information. We have lots of information about pain during sex. And we’ve certainly explored the female sexual response cycle. We’ve clarified the difference between moisturizers and lubricants, and we sell them both in our shop.

So, use the assessment as a fun way to pinpoint areas you might need to work on in your sex life, and then dig into our blog and website for the meat and potatoes.

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