It’s October. That means, yes, Halloween and fall color, the harvest moon, pumpkins, and apples. Also breast cancer awareness. Not necessarily in that order.

To recognize that dubious distinction, let’s review some breast cancer basics, beginning with the most important of the known risk factors that you may (or may not) be able to do anything about. In this case, knowledge is, if not power, at least awareness.

We’ve all lost friends and relatives to breast cancer. Maybe we’ve even had it ourselves. That’s because breast cancer remains the most common cancer for women. Fortunately, we’ve seen some advances in screening and treatment methods, but still one in eight of us (12 percent) will be diagnosed with breast cancer sometime in our lives, and one in thirty-six (3 percent) will die from it.

The good news is that breast cancer rates have been going down since 1989 (although they’ve stabilized lately). Still, every year almost 245,000 new cases are diagnosed and 40,890 women die from it.

Live your life as richly and healthfully as you can.We all carry risk factors for breast cancer, but there are very few absolutes when it comes to who actually gets the disease. Some high-risk women never get cancer while others with a very low risk profile do. The two most universal and unavoidable risk factors are being a woman and getting older. Although about 2,000 men are diagnosed with breast cancer every year, it’s overwhelmingly a female disease. It’s also largely a malady of older women. Two-thirds of invasive cancers are found in women over 55.

Genetics is, of course, a factor, but it may be less significant than we think. Most women (eight in ten) with some genetic predisposition to breast cancer never get it. However, the more genetic factors you have, the higher the risk. So, if you have several genetic risk factors, your chances of diagnosis increase. The most significant genetic factors are:

  • Close relatives (mother, sister, daughter) with breast cancer
  • Relatives with other cancers in your family
  • Some genetic mutations, notably in the BRCA1 and BRCA2 gene.

Other risks that we can’t control include:

  • Early menstruation and/or late menopause increase our lifetime exposure to estrogen and progesterone, while having children and breastfeeding are protective factors.
  • Dense breast tissue. This means that the breast has less fatty tissue and more glandular and fibrous tissue. Not only do extremely dense breasts have a slightly higher cancer risk, but screenings may be less effective and early cancer harder to detect. A discussion with your health care provider will help you understand which category includes you.
  • Race and ethnicity are slightly significant: White women have higher rates of breast cancer, but African-American women are more likely to die from it. Asian, Hispanic, and Native American women are at lower risk for both.

Some risk factors for breast cancer have more to do with lifestyle and treatment choices—and these are factors we can control. These lifestyle choices impact our health and quality of life in a whole bunch of ways, so it’s important to pay attention to them.

  • Obesity. Fat cells release estrone, a type of estrogen, which raises hormonal levels in post-menopausal women.
  • Alcohol consumption. According to cancer.org, two to five alcoholic (any type of alcohol) drinks daily increases the risk of breast (and other) cancer by 1.5 percent compared to women who don’t drink. Cancer surgeon Dr. Jane Pettinga writes, “… alcohol reduction [is] the only dietary change that has science solidly behind it.”
  • Sedentary lifestyle. Evidence is growing that regular physical exercise reduces risk. To reduce breast cancer risk, the American Cancer Society recommends at least 150 minutes of moderate intensity or 75 minutes of vigorous intensity activity each week.
  • Exposure to radiation. This doesn’t refer to the X-rays you get at the dentist’s office. Women who have had radiation treatment to the chest or face before age 30 for treatment of other cancer (like Hodgkins, which makes up the vast majority of young women who’ve had chest wall radiation), for example, are at higher risk.

Cancer is complex and multi-faceted. One risk factor doesn’t–or even several risk factors don’t inevitably equal cancer. There are gradations and mitigating factors and a whole lot of unknowns. Some things, such as exposure to certain chemicals, are considered “emerging risks,” which may or may not hold up under research, while others, such as wearing an underwire bra, have absolutely no supporting evidence.

I think the best approach is to understand your risk profile, but then live your life as richly and healthfully as you can. The most important thing you can do, bar none, is to maintain a healthy lifestyle (more on this in the next post). Then review your plan for screening every year–and follow through.

Every year or so, it seems a new study “discovers” that the stereotype about women becoming less interested in sex as they grow older is, in fact, only a very persistent falsehood. Older women like sex! And, given a steady partner, they’re as satisfied with it as any 30- or 40-year-old. And nearly as active.

That’s the word from last year’s study, conducted by Dr. Holly Thomas, an assistant professor of medicine at University of Pittsburgh Medical Center. In a national survey of almost  2100 women between 28 and 84, but mostly clustered in their 60s and 70s, two-thirds of the older women were sexually active and were as satisfied as ever with their sex lives.

Having a committed partner appeared to be the critical factor: Women were eight times more likely to be sexually active if they had a partner. In fact, sexual satisfaction was unrelated to age, but was more strongly linked to the degree of contentment within a relationship, ease of communication, and the importance the couple placed on sex.

“It’s good to see that menopause is not nearly as important [to sexual satisfaction] as their relationship with the person they’re having sex with,” said Lynnette Leidy Sievert, board member of the American Menopause Society, “because menopause is blamed for so many things.”

Yet, to disrupt the stereotype even further, thirteen percent of sexually active women in Thomas’s study didn’t have a steady partner, so “we shouldn’t look at a woman who’s not married and 60, and assume she’s not sexually active,” says Thomas.

What used to work in the past may not now.These high levels of sexual activity and satisfaction with sex have actually been fairly consistent over time, according to Thomas. A much larger study of 27,347 women between 60 and 79 that was conducted in 2011, also found that over 60 percent were happy with their sex lives, and of those who weren’t, almost 60 percent said they wished they had a more active sex life. The most common reasons for lack of sex were death of a partner, depression, and health problems.

Granted, our approach to sex and what gives us pleasure at 60 is different from sex at 30. For one thing, the physical element, such as attaining orgasm, is no longer as important as emotional aspects, such as intimacy and the feeling of connection with a partner. For another, the mechanics may—or may not—change with age, according to Thomas.

Some older women in Thomas’s study experienced the very predictable issues with libido and orgasm that we discuss all the time at MiddlesexMD. “Many women I talk to say, ‘What used to work for me doesn’t work for me anymore,’ ” noted Thomas.

But other women reported that sex was actually more satisfying than when they were younger, which they often attributed to greater self-confidence in knowing what they liked and in asking for it. Yet other women said that their sexual experience had remained fairly consistent throughout the years.

Apparently, in the absence of health issues or the death of a partner, satisfying sex can continue for a long time. A 2015 British study examined the sexual activity and satisfaction of men and women over 70—and into their 80s. While percentages of sexual activity had declined (to 54 percent for men and 31 percent for women), satisfaction levels for women continued to increase as they aged.

So, while sexual heat may gracefully fade from a red-hot boil to a comfortable simmer, satisfaction levels seem only to increase. Which is kind of sweet and hopeful, don’t you think?


In the last post, we began the discussion of whether masturbation is sinful. This is a controversial topic in Christian circles, and certainly one that many women of faith struggle with. In fact, a respondent to our survey on vibrators asked whether masturbation was against God’s will in the Bible.

So, I’ve rushed in where angels might run for the hills.

In my reading, I noticed an odd thing. Discussions about masturbation were exclusively centered on younger people—either young singles or the married-with-children stage. Not one peep about the specific physiological needs of older women! Nothing about the fact that masturbation is an effective tool for women to maintain a vibrant and healthy sex life within a committed, mature relationship. I find this oversight reflective of the [somewhat ignorant] cultural stereotype that, God forbid, Grandma be sexually active in her golden years.

And, as I mentioned in the last post, the moral quandary regarding masturbation circles around its connection to pornography, lust, and fantasies, about its isolating quality, and about sexual addiction.

Given the probability that Grandma isn’t trolling the porn sites on the internet or lusting uncontrollably while fantasizing about the red-hot dude in a romance novel (not to be stereotypical), I think we can eliminate a couple of the more troublesome aspects of masturbation as it pertains to older women.

I can’t address the issue of addiction to masturbation that seems to worry some Christian thinkers, but I can categorically say that for virtually all women, masturbation doesn’t replace sex with a beloved partner nor do women become dependent on a vibrator in order to orgasm, although it is true that older women tend to need more intense and/or longer stimulation.

Most of the authors I read had no problem with couples masturbating together. It seems that solo masturbation is what opens the door to the “sinful” potential. As for that very narrow Catholic interpretation I mentioned in the last post (that masturbation is intrinsically and gravely disordered), I can only pass along the wisdom of a priest I once overheard. I’m paraphrasing here, but he said that a person can choose to stand under the moral umbrella of church teaching, but if he or she chooses to step outside that umbrella (to masturbate or use birth control, for example), then that person stands alone before God.

At the time, I thought that we all end up standing alone before God anyway, and I could think of worse places to be than before the source of Love itself, who just happens to have made me the way I am.

Which is kind of the point, isn’t it? We are made as sexual beings—as humans, not as angels. Our sexuality is entwined within our love for our partner and for the life that partnership engenders. We can no more deny our sexuality than we can deny ourselves.

True, sex can be disordered, harmful, selfish, and sinful. So can religion, for that matter. Sex is a powerful, sometimes uncontrollable, sometimes disturbing human force, just as it is a God-given, compelling, procreative gift. It has the potential for love and intimacy as well as for degradation and harm. Therein lies the tension and the moral hairsplitting. Sex is a force that’s hard to nail down; it makes us uncomfortable; it challenges our neat categories of morality and sin.

As with so many of our actions, morality depends on our thoughts and motives, which only we can know. For example, masturbating alone within the context of a marriage can either be loving or selfish depending on the motive. When a partner is traveling or ill, masturbation can “take the pressure off” and give our partner the space to heal or to complete the journey. But masturbating to withhold sex or to reject our partner or out of anger is harmful to a relationship.

After a new baby, author and teacher Abigail Rine found that her life was so overwhelming that sex became impossible. “For the first time, I began to dread and fear having sex with my husband, which was incredibly disconcerting,” she writes in this enlightening blog post. “Exploring my own body has been very helpful in making me feel physically normal and like a sexual being. …I am also glad that my husband was able to use masturbation to get sexual release while I was physically unable to have sex with him.”

“Ultimately, the question of whether or not masturbation is healthy for a particular person springs from the question that governs all good discernment: Does this action help me love myself and others more fully and freely, and does it allow me to love God more deeply and with more of myself?” writes spiritual director, speaker, and author Tara Owens.

Finally, to fuel your own exploration, here’s some solid spiritual reading gleaned from several of my minister-friends

Sexual Fulfillment: For Single and Married, Gay and Straight, Young and Old by Herbert W. Chilstrom and Lowell D. Erdahl. This is an exploration of sexuality by two retired bishops of the Evangelical Lutheran Church. The book is a response to their long experience as pastors during tumultuous social upheaval that challenged and redefined homosexuality, marriage, the single life, and sexuality in old age. The book is a pastoral and personal reflection and meditation along with questions for reflection. It doesn’t strive to be a scriptural exegesis or an apology for the Lutheran Church.

Sheet Music: Uncovering the Secrets of Sexual Intimacy within Marriage by Dr. Kevin Lehmen. A surprisingly open and explicit instruction manual for “how to do it, and how to do it better” from this uber-popular Christian psychologist. While he details the “hows” he also places sex front and center in a Christian marriage. A light, straightforward, and humorous read.

Liberating Sexuality: Justice between the Sheets by Miguel De La Torre. A dense and scholarly exploration of controversial sexual topics where religion intersects with class, race, gender, sexual orientation, all from a Biblical perspective.

I readily admit that this question, which was posed by a respondent to our survey on vibrators, is outside my job description. But within Christian circles, to which I belong, it’s one of those nettlesome issues that continues to raise questions—and hackles—on both sides of the fence. So I tread lightly on this topic.

However, as a doctor who treats women during periods of significant hormonal transition that can drastically affect their sex lives and thus their intimate relationships, I have a vested interest in the topic. In my practice, I preach that masturbation, whether with a partner or alone, is an important part of a sexual regimen that keeps tissues healthy and desire alive.

For older women who are single, and who aren’t ready to give up on the possibility of another sexual partner, masturbation is an important way to retain the ability to have sex at all. As we’ve said before, it’s the old use it or lose it conundrum.

For many women of every age, masturbation is the only way they can achieve orgasm. That’s just a physiological fact. Another fact is that most people masturbate. Children masturbate. So do adolescents. So do adult men and women. A lot of them just feel guilty about it.

Prohibiting female masturbation and calling it sinful and repugnant effectively prevents a whole lot of women from ever achieving orgasm at all, and, given enough time, can disallow that nice 60- (or 70- or 80- ) year-old widow from ever having a sexual relationship again because she will lose the vaginal capacity to.

I really wonder if this is God’s will or a very labored and human interpretation thereof.

In order to make sense of this sticky wicket and at the risk of venturing outside my dog run, I did a lot of reading and absorbing of various viewpoints about how the Christian church views masturbation.

Unsurprisingly, opinions were all over the map, from the official and completely unambiguous statement in the Catechism of the Catholic Church (“…masturbation is an intrinsically and gravely disordered act”) to the broad and nuanced perspective of some Christian writers and pastors.

I’ll start with the most uncontroversial point, the fact everyone agrees on: the Bible says nothing… nothing… about masturbation, either for or against, which is an enlightening fact in its own right, given that Biblical authors rarely avoided opining on any number of human activities.

The most common objections to masturbation seems to circle around a concern about entertaining lustful fantasies while masturbating and about its connection to pornography, a concern about sexual addiction, and a concern about its isolating and self-absorbing qualities when sex is ideally an act of sharing and communion.

Because of these concerns, Christian ministers were more likely to label masturbation as sinful.

Since I’ve opened up this can of worms, let’s dig in more deeply in the next post.

You say you’ve had painful intercourse for a few years, and were hoping it would pass. You tend not to want to have sex because the perception of pain outweighs the perception of pleasure. No surprise! And you’re not at all alone, for whatever comfort that gives you.

Once a woman transitions through menopause, she will be postmenopausal for the rest of her life. That means there is no source of estrogen, which results in what we call chronic and progressive vaginal atrophy. The effects of this are increasing vaginal dryness and thinning and narrowing of the vagina. This is not something that will reverse itself over time; without treatment, it only progresses. (I know! This is not something our mothers prepared us to expect!)

You asked. Dr. Barb answered.The majority of postmenopausal women who want to continue to have intercourse need to compensate for the loss of estrogen. The Premarin vaginal cream you refer to using is one option for treatment; it’s a long-term treatment, not a “cure.” It replaces the estrogen your body used to produce, directly in the area where it can have positive effect. This localized hormone treatment is preferred for women whose only issue is painful intercourse. There are fewer risks associated with it than with systemic hormone therapy (called HT or HRT, for hormone replacement therapy), which introduces hormones to more systems in your body.

If your painful intercourse isn’t adequately treated with the Premarin cream, there may be a secondary cause of pain, like vaginismus or vulvodynia. It is important to give feedback to your health care provider to be sure that the sources of pain are properly identified and treated.

It may be that your tissues are now healthy, but because you’ve avoided intercourse you could now benefit from vaginal dilators. Regular use of dilators will gradually stretch your vaginal tissues so that intercourse is comfortable again.

Alas, the sexual enjoyment that came so easily, with so little effort, is now a different story. But I hope you find the efforts of regaining sexual comfort worth the time and energy! I’m privileged to hear from patients about their successes, so I know it can happen!

You asked. Dr. Barb answered.Yes, exercise helps libido in a number of ways, both directly and indirectly. It improves general health and energy levels. It improves sleep and blood supply. And it improves self-image, too, which can make us feel more desirable and more in touch with our sexual selves.

I recommend that women add Kegel exercises to their exercise habits. Increased muscle tone in the pelvic floor increases orgasm response, as well as keeping our organs where they belong and preventing or minimizing incontinence. It’s a complete win!

So yes, get active or stay active. Your body will thank you.

You asked. Dr. Barb answered.There are a variety of reasons that sex can be painful after birth. It may be pelvic floor muscles that are still too taut, injured, or spasmed. There may be some nerve damage that is still healing. In those cases, allow time for recovery–and do be in touch with your health care provider if you have questions or don’t think you’re progressing.

If the mother is breastfeeding, there’s can be a reduction in estrogen that contributes to vaginal dryness. In those cases, a silicone lubricant (Pink Silicone is our most popular in this category) can be very helpful.

In any case, I encourage new mothers to be forthcoming in their follow-up medical visits: Returning to a comfortable sex life is, ideally, a part of the new family “normal”! Whether or not your health care provider asks about your sexual health, please bring up your questions or concerns.

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