If you’re wearing a Fitbit to bed, like a patient I saw last week, you might be seeing pretty colored charts that confirm just exactly how poorly you slept last night. And if you’re like her, it may only be increasing your stress about what you already know: You’re tired! You’d like to sleep through the night!

Yes, as you’re likely tired of hearing, it’s hormones. Estrogen and progesterone are in decline, and the mix of hormones (add cortisol, the “stress hormone” to the cocktail, too) may be less friendly to sleep than it once was. Hot flashes, which can happen day or night, come with a surge of adrenaline, from which you need to recover before you can settle back to sleep.

What you're thinking of in the middle of the night is spam. Delete it!A few of the people I’ve talked to for The Fullness of Midlife, our podcast, have had some light to shed on our sleeplessness. Joan Vernikos, a retired NASA health science researcher, says sleep is “like a cleaning service in an office. …The cleaning service starts out by emptying the garbage cans, by tidying up, picking up—and that’s what happens with the brain during sleep in the various cycles. If you wake up and you don’t sleep well, not only are you going to make mistakes the next day, but you’re not going to detox your brain.”

Menopause can sometimes bring its own befuddlement, right? Memory lapses. Foggy thinking. Well, add in some sleep deprivation and a brain in desperate need of a “detox,” and you can imagine a day that you’d rather forget.

Another podcast guest, Dr. Pamela Peeke, gave us a pep talk about making “sleep hygiene” a priority. She points out the relationship between sleep and diet: We’re much better able to be in control of our appetite—not because we lack self-discipline but because of busy hormones at work in our bodies—when we’re well-rested.

Make “sleep hygiene” a priority? Well, it sounds good. And there’s plenty of reason to do it, from easier healthy eating to clear-headed days. Here’s what it takes:

  • Make your bedroom comfortable for sleep. Is it dark enough? Cool enough? You might want to layer your bedding like you layer your outerwear for a hike on an early spring day—so both you and your partner can be comfortable throughout the night. Consider white noise if sounds are keeping you awake. If now is not the time to invest in your good sleep, when is?
  • Exercise. To patients in my office, I recommend 45 minutes five days a week of real exercise—walking, swimming, biking. Something that gets the heart-rate up. If some part of that can be outdoors, even better, because natural light helps us with our sleep-wake cycles. Get it in early, so you can avoid exercise in the three hours just before bedtime.
  • Stay awake during the day. I know it’s tempting to nap when you’re not sleeping well at night. But napping for more than 20 to 30 minutes can make it more difficult to sleep deeply overnight, which is when that brain detoxing Joan talked about happens.
  • Ease away from stimulants and heavy foods. The effect of caffeine can change as our bodies change. And the relaxing effect of alcohol wakes us up later when we’re metabolizing it. Digesting heavy foods can do the same.
  • De-stress generally, but especially as part of a pre-bed routine. Excess stress is a health challenge for us at any age. While it’s unlikely you can eliminate stress from your life, you can at least develop some routines for putting it in its place before you turn in for the night. Set a routine—yoga for relaxation, reading a novel, writing in a gratitude journal, taking a hot bath—that signals that it’s time to settle down. Avoid screens in the hour before bed, especially contentious text or Facebook exchanges or upsetting documentaries. And remember what Joan said when you’re churning at night: “What you’re thinking of in the middle of the night is spam. Delete it! You can’t do anything about it.”

A perhaps unexpected side effect? Since stress and fatigue are two of the three most common obstacles to sex (the third is lack of privacy), you just might find yourself with a little more romance in your life.

Makes “sleep hygiene” sound a little sexy.

You say that sex is uncomfortable, despite using moisturizers and lubricants. Yes, this is common among women after menopause, whether or not they’ve given birth. You say you feel “less stretched out inside.”

Vaginal dilators for elasticityYes, dilators might be your best hope to regain vaginal “capacity.” The elasticity of the vagina is diminished in menopause, so the use of localized estrogenOsphena, or Intrarosa may make dilator use more successful. These are prescription products that restore health to the vaginal and vulvar tissues. Talking with your health care provider can help to determine if one of these products may be of benefit and which one is the right choice for you.

In the meantime, getting started with dilators sooner than later is good!

You say you passed the menopause mark (a year without menstruating) four years ago. You use a vaginal moisturizer every three days, and are successful with dilator use. Still, you have difficulty with “full and comfortable” intercourse with your husband.

You asked. Dr. Barb answered.I suggest that you take the largest dilator you’ve used in to your health care provider. Explain the situation, and have your provider insert the dilator and do a careful exam to see why there’s a discrepancy between success with the dilator but not with intercourse.

The term “hitting a wall” is most often used with the diagnosis of vaginismus. Vaginismus is involuntary spasm (tightness or tautness) of the pelvic floor muscles. Because this is involuntary, you can’t “just relax” the muscles.

This is a clinical diagnosis that can often be treated with dilators, but may also need pelvic floor physical therapy treatment as well. Your provider will be able to help in that determination and then to direct to you a physical therapist with pelvic floor expertise.

Good luck! It’s worth pursuing to regain that intimacy!

For our mothers, pregnancy was the workplace unmentionable. Once a married woman began to “show,” she was expected to leave her job and begin her new life as a stay-at-home wife and mother. Now, our daughters often have family leave time, breastfeeding rooms at work, sometimes even on-site daycare.

Still, we have a long way to go. Despite progress on many fronts, menopause remains the workplace unmentionable. It makes people uncomfortable. It can be embarrassing; it isn’t well-understood; it is the butt of stereotypes and jokes; it is inevitably linked to being old, infertile and irrational. Heck, too often, we don’t even understand it ourselves.

In the workplace, the universal approach to menopause seems to be “don’t ask; don’t tell.” If you can’t see it, it ain’t happening.

There are, however, a few problems with this approach.

In our mother’s time, women over 50 were a rarity in the workplace. Our mothers didn’t talk about menopause. They didn’t discuss it with their doctors, spouses, or with us, by and large. There weren’t many options for treatment, anyway.

Now, however, while menopause is still in the closet, a lot of valuable employees at the peak of their careers are going through it. Now, most (75 to 80 percent) of women of menopausal age are working. If menopausal symptoms affect job performance and satisfaction, and if many of these problems could be addressed with more flexible policies and a supportive environment, then why isn’t it happening? Why are so many women struggling through the workday when fairly simple solutions could be implemented?

Menopause is prolonged and unpredictable. There is no handbook; it isn’t over in nine months—it can, in fact, last anywhere from four to eight years! Some women sail through without missing a beat while others struggle mightily with emotional swings, sleep issues, brutal hot flashes and night sweats, and a severe hit to self-confidence. Most of us fall somewhere in the middle, and most of us would appreciate a little understanding on the job.

Because we are numerous and at the peak of our career, one would think that accommodation, or at least conversation, would be happening in the workplace. But alas, in the US we are far behind our Western counterparts overseas. In Europe, awareness may be in its infancy, but at least it’s on the radar.

A lot of people are afraid to say what they want.For example, a poll of just over 1,000 women between 50 and 60 conducted by BBC Radio in Great Britain found that over 70 percent of women didn’t discuss their menopausal symptoms with their employer and about 33 percent hadn’t talked about it with their doctor, either. Half of the women surveyed said that menopausal symptoms had affected their mental health and one-quarter said that it made them want to stay home.

“It was such a waste of all that talent and experience that these women had in serving the public,” said Sue Fish, the former police chief who established the force’s first menopause policies in this article. “I was horrified to find out women were leaving early because of the severity of their symptoms. Some had been rebuffed by line managers or they’d chosen not to talk about what they were going through.”

It’s a touchy issue, to be sure. Most of us wouldn’t want to be singled out for special treatment, and most of our colleagues and bosses wouldn’t want to draw attention to our difficulty or make suggestions about fixing it. Yet, competent, productive women still struggle through work situations that could be made bearable with some awareness and a few, simple adjustments.

A web entrepreneur says in this article, “I have friends in senior roles who have had to attend meetings with closed windows where they were almost expiring from heat and drenched in perspiration, fearing that wet patches might appear – but this does not prevent them from continuing to work effectively.”

So, what’s the balance, and how do we begin to move the needle so our daughters don’t have to sweat it out (pun intended) in an oblivious workplace?

The Faculty of Occupational Medicine (FOM), the educational body of the Royal College of Physicians in the UK, has put together some fairly commonsensical suggestions in its “Guidance on Menopause in the Workplace” that were adapted from the European Menopause and Andropause Society.

The guidelines are addressed to both employers and to menopausal-aged female employees, since both sides share ownership of a solution. Guidance for employers emphasizes an atmosphere of openness and dialog, along with training for management. It also suggests that employers provide some access to ventilation and temperature control, some flexibility in work hours, choice in types of fabrics and the ability to layer clothing when a uniform is required, and some ability to move around for sedentary workers.

Menopausal employees are encouraged to learn about this transition and to reach out to their doctors for help and information, to develop techniques, such as note-taking and using a calendar, to compensate for memory lapses, to reach out to colleagues, sympathetic managers and HR personnel for help and camaraderie when possible rather than trying to suffer in silence. The guidelines also suggest using mindfulness techniques to reduce stress and to consider lifestyle changes that are known to ease symptoms: weight loss, not smoking, reducing alcohol use, and exercise.

Working toward a workplace that is accepting and open to menopause is a worthy goal, and now, given our numbers, is an opportune time to crack that resistance. We did it before, and for our daughters’ sake, we can to do it again.

You asked. Dr. Barb answered.You describe your experience as “incredible pressure and pain,” and “deep aching pain.” You also said that you’ve had some varicose veins in your legs and have had some removed. Your research led you to vulvar varicosities, which does sound like a possible answer. These are varicose veins in the vulva, which are not all that common but do occur (often during pregnancy).

There are two options I’d like you to consider: The first is a good pelvic floor physical therapist. She or he can assess structurally whether there is evidence of a source for your pain. A great therapist can work magic! Really, they can.

The second option is a vein specialist. They can do an ultrasound assessment of vein function, even in the vulva, and try to help understand if that is what might be causing your discomfort.

Good luck on your journey!

One of the benefits of my work with MiddlesexMD is the networking that makes it more likely that I’ll run into medical information, over-the-counter products, articles and books that could be helpful to my patients, and, of course, the interesting conversations that turned into our podcast, The Fullness of Life.

Love Worth Making book coverI received an advance copy of Love Worth Making: How to Have Ridiculously Great Sex in a Long-Lasting Relationshipby Stephen Snyder, MD, a month or so ago. Steve is a couples therapist, psychiatrist, and writer, as well as associate clinical professor of Psychiatry at the Icahn School of Medicine at Mt. Sinai in New York City. While I’ve met him—so far—only via email and his written words, I know we share some perspectives: that intimacy remains important to us no matter what our age, that men and women do have some differences in their approaches to love-making, and that there’s nothing wrong—and lots that’s right—about seeking tools that help us!

I think it’s useful to hear men’s perspective on sexuality, too, so when Steve offered to contribute to this blog, I accepted! Read on for more from Stephen Snyder, “sex therapist in the ‘hood.”

Several years ago, a merchant in my neighborhood learned that I was both an MD and a sex therapist. The next time I was in his shop, he asked me if I could get him some Viagra.

“How long have you had erection problems?” I asked.

“I don’t,” he answered. “But my wife and I have been married for 30 years. To tell you the truth, sometimes I’m too tired or preoccupied to get hard without the Viagra.”

What was this man’s problem, exactly? He wanted to have sex with his wife, even though he wasn’t feeling that strongly turned on. Evidently there were other reasons he wanted to do it.

Sound familiar? Of course: He wanted to make love like a woman.

Things women take for granted about sex

Women can have sex with their partners any time they want. They don’t have to be very excited. Sure, some lubricant might be required, especially over 50. But the absence of peak excitement isn’t necessarily a deal-breaker.

A woman can make love for other reasons besides strong desire. To feel close or emotionally connected to her partner. To promote loving feelings. Or just for the simple pleasure of the experience. Even occasionally to keep a partner happy, even though she might be too tired or preoccupied to be really into it. A useful book on the subject calls it “good-enough sex.”

One wouldn’t want all one’s sex experiences to be like this. But once in a while it’s okay.  Especially if the alternative is not to make love at all. If there’s one thing that sex research repeatedly shows about successful long-term couples, it’s that they keep having sex even when if the sex isn’t always earth-shaking. The ritual itself is important.

Men traditionally haven’t been able to do sex very easily under conditions of lower arousal.  Especially over 50, when it ordinarily takes more stimulation to stay hard than it did at 20. If a man, for whatever reason, hasn’t been strongly turned on, conventional sex hasn’t usually been an option for him.

Viagra changed all that. Since the blue pill came on the market in 1998, a man can take Viagra and have sex even if he’s tired or preoccupied and just wants some loving and affirmation but isn’t feeling peak excitement. In fact, just having a good erection can help a man feel more in the mood.

Is Viagra good for sex?

There is often strong partner resistance to a man’s boosting his erection through chemistry, though. Women especially are used to the affirmation that occurs when a man gets hard (as Mae West famously put it) simply because he’s “happy to see her.” It’s worth it for a man to communicate that he needs sex for closeness and affirmation and pleasure as well. Just like she does. And that worrying about his erection just gets in the way.

Some couples worry whether taking Viagra under such conditions is a wholesome or natural thing to do. If it just takes more sexual stimulation now to keep him hard, wouldn’t it be more natural to simply intensify the excitement?

Maybe, but not necessarily. Intensifying excitement sounds like a great idea. But in practice, having to do things to get the man hard enough can be a bit of a burden. And it can take time, sometimes so much time that the moment is lost.

Sound familiar? Of course. It’s the same predicament that women find themselves in when they can’t get lubricated or can’t climax. Deliberate efforts to manufacture excitement often backfire. They usually aren’t very erotic.

My advice? It depends on the couple and the situation. But sometimes Eros is best served by taking the Viagra. Then a man can stop worrying about his erection, and get back to making love.

Sometimes it’s best for a man once in awhile to make love like a woman.

Sounds like you’ve been doing a number of the right things: You’ve been using dilators, a vibrator, lubricant, and vaginal moisturizer. It sounds like you’re at a point where localized estrogenOsphena,  or Intrarosawould be helpful for you to achieve your desired outcome.

You asked. Dr. Barb answered.Any of these prescription drugs will provide elasticity, a critical factor for getting the “stretch” needed with the dilators. Take your dilators in to your health care provider and have this conversation, too. He or she can help you determine whether you can get further capacity with the methods you’re using or whether, as I suspect, you need to take the next step and add a prescription to your routine to restore health to the vaginal tissues.

It’s hard to get to the final goal without that option–and that final goal is definitely one worth working for! Good luck.

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