Archive for November, 2011

Breast discomfort, bloating, acne, and cramps are all symptoms associated with perimenopause, I’m afraid. If your periods are irregular but still happening, what’s going on is that your ovaries are not quite done producing hormones, but the fine-tuned system of regular ovulation is winding down. Some chaotic and unpredictable hormone shifts result, contributing to the symptoms you’re experiencing.

What you describe sounds perfectly normal and will likely continue to some degree until menopause, when most of these symptoms will subside. Menopause is defined as 12 months without a period, and the average age for menopause is 51. It shouldn’t be too long a wait!

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My conversations with patients, blog readers, and visitors to MiddlesexMD tell me that once a person’s gotten past her own discomfort with the idea of a vibrator, there can lurk another obstacle: How to introduce it to intimacy with a partner.

I’ve heard from both men and women on this topic: Both have asked how to introduce a vibrator into a relationship or how to overcome resistance. A recent study done at the Center for Sexual Health Promotion at Indiana University suggests some couples have figured it out. Half of both men and women have used a vibrator with a partner at least once. Slightly more men than women agree that vibrators can make sex with a partner more exciting, but for both the number is close to 60 percent.

And we know from other research that about two-thirds of women don’t experience orgasm with penetration alone; the IU study says half of women agree that a vibrator helps.

But in spite of that evidence that couples are using vibrators, and that women find them satisfying, there’s still resistance. I talked to Mary Jo Rapini, psychotherapist and one of the MiddlesexMD advisors, to learn more.

The first issue for some women is their preconceptions, Mary Jo says. “If you think of vibrators—or any other part of sex—as ‘creepy,’ you’re showing resistance. Resistance is a product of your own thoughts, which means you can change it and open yourself up to communication and growth. My first request would be that she use the word ‘uncomfortable.’ This opens up a wonderful conversation—if you’re uncomfortable with something, you can add something else to lovemaking, and not necessarily all at once. You might not be comfortable with a vibrator, but you may like being massaged during lovemaking with wonderful massage oil. Lovemaking is exciting and it’s so healthy for the heart, immune system, and hormone levels; I encourage women—and couples—to try new things, slowly, without rejecting the concept of lovemaking with new items.”

“Women are sometimes reluctant to own their own sexuality,” Mary Jo says, which works against introducing a vibrator—and other things—into a couple’s intimacy.

“Men are so visual in regards to sex,” Mary Jo says. “Many men enjoy watching their partner masturbate with a vibrator—especially if their partner is able to enjoy it. Men love watching the woman they love enjoy sex. They also want to please the woman. When the woman is able to let the man hold the vibrator for her, or use it gently on him, he begins to see the benefits.

“He may feel rejected if she prefers the vibrator to him, but including him and showing him what feels best being touched is a big turn-on for men. If she can talk about what feels good, how she likes to be touched, the intimacy will be a thousand times stronger.”

The IU study, by the way, confirms that seventy percent of men don’t find a vibrator intimidating during sex.

But that may be beside the point. The real focus, Mary Jo says, is something different: “Sex is not about the penis or vagina, but your ability to let go, explore, and broaden your awareness and understanding of your sexual self—and your partner. Being able to express yourself sexually and feeling safe and secure in that relationship heightens your health both physically and emotionally.”

We’d love to hear your experiences and questions!

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In the course of our conversation about vibrators, I asked MiddlesexMD medical advisor Dr. Michael Krychman how he recommends that his patients begin to use a vibrator. Here’s what he says:

“Get to know your vibrator. Take it out of the package and learn how it works, how to charge it or what kind of batteries it takes. When it’s charged, play with the buttons, turn it on and off. How many speeds and settings does it have? Wash your vibrator well before using it; use warm water with a mild soap and rinse it well so that no residual soap remains. If it isn’t waterproof, be careful not to get any water near the battery case. Check for sharp edges or seams.

“Start on your own. Even if you’re planning to use your vibrator with a partner, it’s a good idea to check it out by yourself first. You’ll feel less self-conscious and you can really concentrate on how it feels. Make sure you have enough time and privacy. If you have roommates, children, thin walls, or nosy neighbors, turn on some music, shut the blinds, and use blankets and comforters to mute the sound.

“Play with the lights turned on. Not everyone is comfortable with this suggestion, but I think playing with a vibrator with the lights on can be very educational and useful. You can discover specific places on your body that are rich with nerve endings and ready for enjoyment and stimulation. You can use this information yourself and share with a lover when you’re ready.

“Turn the vibrator off before you turn it on. Get comfortable with the feel of the vibrator on your body. Run it along your body without even turning it on. Notice how it feels. Press it firmly against your skin; press it onto you body and massage your muscles. If the vibrator is made of a hard material this will probably feel nice. If the vibrator is a soft rubber and doesn’t feel smooth against your skin, try it on top of your clothing. This isn’t meant to give you an orgasm, but it’s a gentle and non-threatening way to introduce your body to the vibrator.

“Move your vibrator from the outside in. Once you turn it on, start by touching the vibrator to your body; this will help you understand the vibration sensation. Even though vibrators are used mostly around the vulva and clitoris, get a feel for the vibration all over your body, including touching the breasts and other areas that feel good. Slowly move to the more sensitive parts of your body.

“Don’t be in a rush: Explore every part of your body. Vibrators never get tired, and they let you explore every inch of your body for sexual pleasure. Many women find that one side or one part of their clitoris responds to vibration more than another. Don’t rush: Leaving a vibrator in place can allow it to establish sensation connections that previously weren’t there. Adjust the speed, pressure, and angle of the vibrator. Most vibrators have multiple speed settings; always start on low and work your way up. Experiment with applying different pressure. You may enjoy a lot of deep pressure with clitoral stimulation.

“Most women use vibrators for external stimulation, but as long as your vibrator is safe for it, there’s no reason not to try penetration. While far more nerve endings are outside the vagina than inside, lots of women enjoy penetration with a vibrator. A vibrator that is safe for penetration will be smooth, have no rough edges, and won’t absorb bodily fluids. Again, start slow and get yourself aroused by using the vibrator externally first.

“There are just two things I caution women about: First, make sure you’re using the right lubricant with a vibrator. Silicone-based lubricants will degrade silicone vibrators. And if you’re sharing your vibrator outside of a monogamous relationship, put a condom on it.”

Sounds like good advice! And getting acquainted with a vibrator yourself will help you introduce it to your partner, too–which I’ll focus on in our next post.

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Science under the Romance

If you’ve followed this blog for a while, you know that I’m a fan of vibrators. From talking to my patients, I’m well aware that not everyone is as comfortable with the idea—and the reality—of them as I am.

We’ve been talking with the MiddlesexMD medical advisory board about the adoption of vibrators. Dr. Michael Krychman, one of the members, sent me this history of the vibrator:

Steam-powered vibrating devices were patented in the late 1860s and 1870s by George Taylor. The first electromechanical vibrator was designed in 1880 by British physician Joseph Mortimer Granville, who intended it to be used for massage of male skeletal muscles.

Doctors originally used vibrators or self stimulators as a cure-all for female ailments: female hysteria, pelvic pain, nervous tension and a wide variety of gynecological complaints. In the 1920s, vibrators became associated with pornography and illicit sexuality. Only recently have sexual accessories and vibrators been favorably viewed as adjunctive medical accessories to help restore or enhance sexual response.

Well, I’m glad I don’t have to recommend a steam-powered device to my patients! But Michael’s response makes me think further about our attitudes about what’s “natural,” “sexual,” and “medical.”

One of the objections to vibrator use I hear is that they’re artificial—and this from users of microwaves, hair dryers, and Botox. That contradiction makes me think there’s something more going on. I think women of my generation like sex to be “romantic”—and so do I! But I’m guessing that my medical training has made it easier for me to acknowledge that underneath the romance is a real physical body, and the body encompasses a whole lot of science.

Michael confirms that “For some women, a vibrator might make the difference between adequate stimulation and the ability to achieve an orgasm—or not. About two thirds of the female population are not able to reach an orgasm with penetration alone.”

As a physician working with women who want to maintain their sexuality (and you know it’s good for you!), bypassing the vibrator would be like refusing to use a pacemaker or an artificial valve. The fact that a vibrator is erotic and fun? Well, that’s just a bonus.

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Maybe you remember reading Our Bodies, Ourselves in the 1970s. Maybe for you, as for me, it demystified your own anatomy. Maybe that knowledge empowered you with a sense of self-determination. For a few people, as for me, it was liberating and challenging enough to inspire a career in medicine.

And even if you don’t remember reading the book, you were probably affected anyway by the changes toward women’s health care that it ignited.  “Women were treated as ‘small men who have babies,’” says Dr. Susan Love, a well-know surgeon and breast cancer specialist. “Men were the model, and women were sort of this extra thing.”

Our Bodies, Ourselves challenged that paradigm. With explicit, well-researched, and no-nonsense information about women’s bodies and their sexual and medical issues, the book “changed the basic discourse” within medical circles and cultures around the world.

This approach was revolutionary. The book began in quintessential female style, almost literally around the kitchen table when a group of women began meeting during the summer of 1969 to research their collective questions about women’s health. They compiled a 193-page course called “Women and Their Bodies.” The first book under the present title was published in 1971 and quickly sold 250,000 copies. It was, apparently, a topic whose time had come.

Our Bodies, Ourselves turned 40 this autumn. The Boston Women’s Health Book Collective—which grew from that first group of girlfriends—has now published several books targeted toward various demographics, including Our Bodies, Ourselves: Menopause, so the generation that came of age during that seminal edition can grow old with this one.

While health issues have changed (HIV/AIDS wasn’t around in 1971, for starters), the perennial appeal of Our Bodies, Ourselves, which now includes the book, the website, and the collective—the group of women who run the whole shebang and who work together to compile the books—remains strong. The group is marking this milestone with a new edition, which includes entries from over 300 contributors.

Even in this post-feminist, technological era, where health information is a few clicks away and women are more strongly represented in medicine than ever, Our Bodies, Ourselves remains a practical, “girlfriend” guide for women. It may (and has) been argued that it created a new genre.

“The legacy of Our Bodies, Ourselves is that it spawned a whole new kind of book,” said Courtney E. Martin, an editor at Feministing.com in a recent interview, “like your best friend sitting down in a room with you and telling you about your body and how it works without any embarrassment.”

Kind of like this blog, we hope.

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Libido is, at best, complicated. Testosterone is the hormone that is linked to libido for women as well as men. After about age 25, our testosterone levels are slowly dropping. It’s estimated that a 50-year-old has about half the testosterone she once had.

I see this phenomenon with increased libido in perimenopause from time to time. Testosterone interacts with other circulating hormones, and it seems to be the relative balance and interaction of these hormones, not the absolute levels of each, that for some women works very favorably during perimenopause. Relatively speaking, testosterone may have some “dominance,” even though the levels are lower than they used to be. Enjoy!

There are some other possible factors: Obese women tend to have slightly higher testosterone levels, and some women have had weight gain in perimenopause. Or, because we’re complicated sexual creatures, it could be the empty nest or something else entirely (for some, the absence of “that bothersome uterus”).

In general, women do experience a loss of libido with menopause, but the loss is not uniform across the board. We can hope you are that woman who doesn’t lose interest. In the meantime, seize the moment!

If you’re wondering when you might move from perimenopause to menopause, I’m afraid we can’t accurately predict that timing. We can only say that women, on average, become menopausal about age 50. Ninety percent of women have four to eight years of changed—and changing—menstrual patterns before becoming menopausal. Blood work is accurate in understanding estrogen, progesterone, and FSH levels for the day of the test, but it doesn’t accurately predict anything. Testosterone levels have fewer day-to-day fluctuations, so accurate measures can be made.

Perimenopause is a time to tune into your body, because as you move into menopause, your symptoms will be the best indicator of what’s actually happening.

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Whether you were already menopausal or were abruptly deposited into menopause after treatment for your cancer, you’re probably familiar with what happens to your vagina when you lose estrogen.

You may experience the burning, itching pain of thin, dry vaginal walls and fragile skin on your genitals. You don’t lubricate like you used to, so sex can be difficult or painful. Or, if you’re experiencing the muscle spasms of vaginismus, sex may be impossible. Less estrogen is a good thing for some cancer treatments, but it’s darned tough on the vagina and, by extension, on your sex life as well.

So, while vaginal health is important for all women during menopause, it’s critical for those undergoing cancer treatment. Your vagina and pelvic floor need a lot of TLC right now to stay comfortable and responsive. Fortunately, compared to the other things going on in your life, taking care of your bottom is usually straightforward and inexpensive. Besides, keeping your vagina in good shape might eliminate one problem area and allow you to stay in touch with your sexual self, too.

Consider this four-part approach to caring for your vagina and pelvic floor.

First, use vaginal moisturizers and lubricants.

Moisturizers are your first line of defense. These are non-hormonal, over-the-counter products that are intended to keep your vagina hydrated and to restore a more natural pH balance. They should be used two or three times a week, just as you’d moisturize any other part of your body. Replens, Yes, and Emerita are examples of moisturizers.

Using moisturizers is important whether or not you’re having intercourse. It should just be part of a regular health maintenance regimen.

Use lubricants liberally before intercourse, on sex toys such as vibrators, and any time you touch the delicate tissue on your genitalia. Also apply lubricant to your partner’s penis.

At this point, keep your lubricants plain and simple—no scents or flavors; avoid warming lubes. Don’t use any product with glycerin, which can create an environment conducive to yeast infections, and don’t use petroleum-based lubricants.

Second, keep your pelvic floor toned. “The pelvic floor is really important in keeping your internal organs in place, preventing incontinence, and enhancing sexual pleasure,” says Maureen Ryan, nurse practitioner and sex therapist.

Plus, knowing how to relax your pelvic floor muscles is helpful if you’re experiencing the involuntarily spasms of vaginismus.

Kegel exercises, in which you flex and relax the muscles around your vagina, will tone the pelvic floor. Or, you can purchase exercise tools to tone your pelvic floor muscles. This is a great way to make sure you’re exercising the right muscles.

Third, use dilators if your vaginal capacity is compromised. Dilators are cylinders that come in sets with various sizes. They’re meant to gradually increase the size and capacity of the vaginal opening, which can be important, especially after some cancer surgeries and treatments that constrict the vaginal opening or create scars and adhesions.

To some extent, dilators are helpful just to reassure you that you can tolerate something in your vagina again.

Start with the smallest size dilator, lubricate it, and gently insert it as far in as you can tolerate. Try doing kegel exercises, tensing and relaxing your pelvic floor muscles. Can you feel your muscles close around the dilator? Keep it in for maybe ten minutes and repeat this exercise several times a week. Move on to the next largest size when you can tolerate it.

Fourth, use a vibrator (lubricated, of course). Self-stimulation increases blood flow to your genitals and helps reacquaint you with the feelings and sensations of your body. The more stimulation you can bring to the area, the healthier it will be.

The point is to keep the vulvo-vaginal area moist and flexible, to increase blood flow, to stay responsive, to maintain capacity, so that when you and your honey are ready to start your engines, you’ll both enjoy a smooth ride.

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