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Getting old ain’t for sissies, and neither is menopause. For all you guys out there with menopausal partners, maybe you’ve noticed her, um, lack of patience. Maybe you’ve been caught in the cross-hairs of her mood swings. Maybe you’ve been awoken at night to her tossing and night-sweat-induced turning.

And maybe she just isn’t interested in sex anymore.

With some work, you'll weather the storm and emerge stronger than before.In my practice, I usually hear the woman’s side, but I know you’re an uncomfortably intimate co-pilot on this journey. You may be feeling confused, hurt, rejected, and helpless. This person you thought you knew is changing before your eyes. You don’t know how to help; you don’t know what this means—and it seems to be going on forever.

You miss the sex, the intimacy, the person you used to know. You miss the way things used to be, and you don’t know if or when any of these things will ever come back.

You aren’t alone. Says 70-year-old Larry in this article: “When she got to about 65 it started to change. Intercourse became painful for her and she developed an allergy to semen. Now intercourse is out of the question and she has no desire for anything other than hugs.”

Life—and sex—does change during menopause, but that doesn’t mean you’re doomed to a relationship without intimacy forever. Shifting ground is treacherous, but with some work on both your parts, you’ll weather the storm, and emerge stronger than before.

Here’s what you can do:

Walk a mile in her shoes. Depending on the intensity of her symptoms, your partner is going through moods that may swing wildly without rhyme or reason, and over which she has no control. She may experience uncomfortable and embarrassing hot flashes frequently and unpredictably. She may toss and turn at night, waking soaked with sweat.

She may gain weight, lose her hair, and generally grow old before her own eyes. This can be particularly galling in a culture that is completely besotted with youth and beauty. “A woman’s self-esteem influences her sexuality, and low self-esteem is associated with sexual dysfunction,” according to this article.

What you can do: Educate yourself on menopause. Understand the trajectory and the tortuous path it takes. Read this blog. Learn about comfort measures and possible treatment options. There are many. She may be too embarrassed or miserable to do her own research or even to bring it up.

Armed with understanding, you can reassure and support. You can say, “You seem pretty down [or angry, or forgetful]. Are you okay? What can I do to help?” That alone may make an intimate connection, but this isn’t about sex right now. This is about reaching out to your lover who’s going through one of the most significant transitions in her life.

Now that you’ve asked, listen. And keep listening. Be an ally and a partner in this journey. Check in frequently to see how she’s feeling. Don’t advise unless you’re asked. Just listen. If she talks with her girlfriends, fine. But let her know you’re in her court.

Most important—reassure her that she’s still beautiful to you. Girlfriends can’t do that.

Nothing says love like taking out the garbage.Follow up with actions. Don’t sit on the couch while your partner makes dinner and then watch the game while she cleans up. Nothing says love like taking out the garbage or doing the dishes so she can take a bath.

Once in a while, go out of your way. Cook a special, romantic meal. (You can order from one of those home-delivered meal plans, like Blue Apron or HelloFresh.) Send her flowers or plan a surprise getaway weekend. No expectations; no pressure—just an expression of your love and caring.

Get healthy. I harp on this all the time, but both you and she will feel a whole lot better (and feel more like sex) if you’re eating healthfully, maintaining a good weight, and exercising. You can gently encourage walks together, healthy eating, and good sleep habits. Don’t be a drill sergeant, but your good example and attempt to make it a couple’s thing can’t hurt.

Shake things up. Boredom is a slow leak in the sex balloon. I’m not talking about having sex on the kitchen table. But just exploring the array of tools and props that can add sizzle and simple comfort to the routine. Since your partner is probably experiencing the common menopausal complaints of dry vaginal tissue, painful sex, loss of libido, you’ll have to shake up the routine anyway.

You’ll need lots of foreplay, lots of lube, and some toys. Try reading an erotic story or watching a sexy movie together to get your heads in the game. Don’t downplay the effect of a romantic ambiance—candles, incense, music. Use pillows to cushion joints and prop up the bits that matter. Try positions that might relieve pressure, offer a different kind of contact, or just be more comfortable.

Take your time and maybe forgo the literal act if the timing’s off. You can kiss, cuddle, spoon. You can use your tongue and mouth. You can masturbate together. Take the pressure off the performance and focus on trust and intimacy.

Don’t take it personally if she just doesn’t respond the way she used to. It isn’t about you, and it isn’t personal.

Once in a while, go out of your way.Find a counselor, if necessary. Generally, celibacy isn’t a healthy state in a marriage. If you’ve reached an impasse, and there’s no way out, you may have to get some help. This isn’t an admission of defeat; it’s a sign of maturity and wisdom to look for help when you need it. If your wife won’t go, you need to find a therapist for yourself to acquire the emotional tools to navigate your relationship.

I’ll leave you with the beautiful and encouraging counsel from the perspective of a 40-year marriage: “…we have found ways to enjoy sex with each other that do not need penetration. Mutual masturbation and oral and always with some nice foreplay, we still enjoy each other.

“I miss intercourse…but we make it work, and it’s usually fun! I hope some men will read this and decide there’s a way to stay happy with the woman of your youth.”

Lots of attention has focused on the finicky female orgasm in recent years, from Dr. Rosemary Basson’s model of the female sexual response cycle to the helpful finding of just how female anatomy influences the probability of vaginal orgasm.

A new study from Chapman University, Indiana University, and the Kinsey Institute colored in some details of female sexual response, in part by rounding up a wide net of participants. Over 52,000 men and women between the ages of 18 and 65 responded to an online survey, including a more robust sample of those who identify as gay, lesbian, and bisexual.

There's significant misunderstanding between Venus and Mars.The take-away from all this analysis was the jaw-dropping finding (tongue in cheek) that men (95 percent) orgasm dependably, while women, not so much (65 percent). About 44 percent of women said they rarely or never reach orgasm with vaginal intercourse alone, a number that is quite low compared to other studies suggesting that fully 70 percent of women don’t orgasm with vaginal penetration. These numbers point (again) to some very significant differences in sexual response, which in turn, lead to significant misunderstanding between Venus and Mars.

“About 30 percent of men actually think that intercourse is the best way for women to have orgasm, and that is sort of a tragic figure because it couldn’t be more incorrect,” said Dr. Elisabeth Lloyd, a professor of biology at Indiana University and author of The Case of the Female Orgasm in this article.

Additionally, while 41 percent of men think their partner orgasms frequently, far fewer women (33 percent) say they actually do orgasm. The researchers note that this difference could be due to women faking orgasm for several reasons: “to protect their partner’s self-esteem, intoxication, or to bring the sexual encounter to an end.”

The researchers were particularly interested in the disparity between how dependably lesbian women orgasm (89 percent) versus heterosexual women (that 65 percent figure). They theorize that this is due, in part, to women having a better anatomical understanding of each other’s needs.

The headliner result of all those survey is a “Golden Trio” of sexual moves that the researchers say are almost guaranteed to induce the Meg Ryan-style “Yes! Yes! Yes!” in women: clitoral stimulation, deep kissing, and oral sex. Even without vaginal penetration, 80 percent of heterosexual woman and 91 percent of lesbian women were able to orgasm dependably with this magic trio. (Although deep kissing and oral sex seem either mutually exclusive or tremendously acrobatic.)

The research noted that women who orgasm more frequently also have sex more frequently and are more likely to be satisfied with their relationships. Whether satisfying sex is the chicken or the egg—a contributor to a satisfying relationship or an effect of a good relationship, it’s safe to say that the two go hand-in-hand. Good sex and good relationships are both enhanced when partners communicate about what works and include a healthy dollop of fun and flirtation.

“I would like [women] to take that home and think about it, and to think about it with their partners and talk about it with their partners,” said Lloyd. “If they are not fully experiencing their fullest sexual expression to the maximum of their ability, then I think our paper has something to contribute to their wellbeing.”

Regular or decaf. White wine or red. Chocolate or vanilla.

Choices abound. Some are inconsequential—the whim of the moment. Others matter, like your choice of health care provider. I’d like to make the case that, although you may be well past childbearing years, you haven’t outgrown being a woman. Ergo, you still have very unique and specific needs that are best served by a specialist with training and experience in all things feminine.

Most gynecologists see an abrupt migration of their older patients to internal medicine or family practice providers. “…between ages 45 and 55, you start to see a very sharp decline in the number of encounters between women and their ob/gyn–and a mirror-image rise in visits to internal medicine,” says Dr. Michael Zinaman, director of reproductive endocrinology at Loyola University Medical Center in this article.

Not for one moment am I suggesting that this is a bad thing. General practitioners take a broad and thorough approach to patient care. In a typical exam on an older woman, an internist would screen for diabetes, colon and other common cancers, osteoporosis, high blood pressure and cholesterol, anemia and other blood disorders—basically, the whole enchilada. Since heart disease is the #1 killer for women, it’s a good idea to have this type of broad screening every year.

Internists also counsel with patients about lifestyle issues, such as smoking or weight control, diet or exercise (which I also do regularly). And they might refer and coordinate a patient’s care with various specialists.

So, why might a woman who no longer needs reproductive care and who may or may not even have her reproductive organs continue to see a gynecologist? Well, for all the stuff we talk about on this website, for starters.

Older women have specific needs and vulnerabilities for which gynecologists have deep and specific training and experience. The incidence of breast and ovarian cancers increase with age, for example. And although internists may do pelvic exams (and note that “may”; even when, after age 65, we no longer need a pap smear, we still need regular pelvic exams) and order mammograms, gynecologist have years of practice in detection and treatment.

Then, there are all those everyday annoyances of menopause and an aging reproductive system—pelvic organ prolapse, incontinence, hormonal disruption, and all those vexing sexual changes we address here on MiddlesexMD. When it comes to treating these quotidian challenges to health and well-being, gynecologists are simply the specialist. We’re more likely to know about new treatments and medications; we’re more likely to catch anomalies; we’re very attuned to kinds of changes that can signal something serious.

But the bottom line? This isn’t one of those either/or decisions. You can choose between a chocolate sundae and a frozen yogurt, but the choice isn’t between a gynecologist and a general practitioner.

You need both. And both healthcare providers need to be working together for you. “A collaborative approach would be very good,” said Dr. C. Anderson Hedberg, head of general internal medicine at Rush-Presbyterian-St. Luke’s Medical Center.

In one study comparing the type of screenings women tended to receive from primary care doctors as opposed to gynecologists, researchers found that gynecologists were more likely to screen for cervical and breast cancers, and osteoporosis, while primary care doctors were more likely to test for colon cancer, high cholesterol, and diabetes.

I’m thinking you wouldn’t want to miss out on any of this fun stuff, and you sure want to know early on about issues or warning signs. But in the end, you make the judgment calls about your health. You decide what doctor to see and how often and whether or not to follow medical advice. That’s as it should be.

Having the right medical team on your side simply gives you the ability to make the best, most informed choices.

You asked. Dr. Barb answered.I’m not sure which “tightening product” you’ve seen. The only way to tighten the vagina is to tighten the surrounding muscles. Kegel exercises (we give instructions on our website) target the muscles of the pelvic floor. And many women find that exercise tools (like vaginal weights or a barbell) helps them be sure they’re flexing the right muscles. I also recommend the Intensity Pelvic Tone Vibrator, which uses a combination of electrical pulses and vibration to build pelvic tone.

You asked. Dr. Barb answered.The sexual arousal creams and gels are effective, and beneficial to most women who use them. Like our category of “warming lubricants and oils,” they typically use an ingredient like menthol, mint, or pepper to stimulate circulation, which increases responsiveness during intimacy. Read the instructions for the product you intend to use, to be sure you understand whether it’s for internal or only external use; lubricants are generally safe for internal tissues.

Arousal and warming products have the potential to cause some irritation for those women with significant atrophy, or thinning of the vulvovaginal tissues. I recommend applying a small amount to the genitals in advance of sex to make sure it’s comfortable and pleasurable.

You asked. Dr. Barb answered.Intrarosa is a new product for treating vaginal atrophy, approved by the FDA in November of 2016. It will be available by prescription only; it’s not yet in pharmacies but is likely to be later in 2017. The clinical trials for Intrarosa are favorable for treating vaginal atrophy, or genitourinary syndrome of menopause causing painful intercourse. It is an adrenal hormone, prasterone (dehydroepiandrosterone), formulated as a once-a-day vaginal insert.

MonaLisa Touch is a laser treatment for vaginal atrophy, also known as genitourinary syndrome of menopause. I explained the treatment option in a blog post a few months ago.

You asked. Dr. Barb answered.The treatment is quite effective for most patients, but it is costly. As a new procedure, it’s not covered by most insurance companies; without insurance coverage the expense (cost varies by region, but figure $1,500 to $2,000 for the three required treatments) is a limitation for many. The procedure needs to be updated regularly, probably about once a year for most women.

We also lack long-term data on its efficacy and side effects. We are very hopeful the clinical trials will soon be available to assure its effectiveness and safety.

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