Archive for May, 2013

There’s nothing like pain to shut down the party.

Anyone suffering from chronic joint pain knows that it squeezes the fizz right out of life. When it hurts to move, not only is the ability to accomplish everyday tasks limited, but quality of life, self-esteem, and mood are also affected. Not to mention one’s sex life.

Bottom line? Viagra won’t do a couple much good if joint pain makes sex unbearable.

Makes sense when you think about it, but the extent to which joint replacement perked up the recipient’s sex life was unexpected. The results of a small study conducted by orthopedic surgeon, Dr. José Rodriguez were reported recently in The New York Times and other media.

The study involved a series of 3 surveys of 147 patients who had received either knee or hip replacement. Both men and women participated in the study; the mean age was just under 58 years old.

Before joint replacement, 67 percent had problems with sex, which ranged from pain and stiffness to actually being unable to get into position. Additionally, almost all of them (91 percent) reported a diminished sense of well-being.

In post-surgery interviews, 90 percent of patients—both men and women—reported an improvement in their sex lives, which included an increase in libido, greater stamina, and more frequent intercourse. Hip or knee replacement “offers improvement in sexual activity and overall sexuality to patients after surgery, especially if (sexuality) is affected before surgery,” said Dr. Rodriguez in an article in Science Daily.

Too frequently, however, matters of intimacy don’t figure into the conversation, either before or after joint replacement, and that’s too bad.

A small percentage of respondents to Dr Rodriguez’s study were actually afraid to have sex, often for fear of damaging their new joint. A few tips could have addressed that anxiety. The quality of a patient’s love life is directly linked to overall well-being and should be part of a pre-surgical assessment as well as post-surgical guidance. Such a conversation could address any fears and increase a patient’s confidence.

Orthopedic surgeon Dr. Claudette LaJam gets so many questions about sex after joint replacement that she created a page on her website to discuss the issue. That page now gets more hits than any other on her website. (Another excellent source of information is here.)

So, while no one looks forward to surgery, the possibility of better sex could give the dark cloud a silver lining—and also perhaps give those who’ve been dodging the issue another gentle nudge to consider the benefits of joint replacement.

“I never want to see someone’s intimacy with a partner destroyed because of a joint problem,” Dr. Rodriguez said in an article in a recent AARP magazine. “Sexual function needs to be discussed with patients when we make routine evaluations. I’ve found most patients to be very receptive to talking about it.”

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I always thought of Tantra as one of those Eastern practices, vaguely connected with the Kama Sutra, and having to do with chakras and energy and contorted positions.

While it does involve some of these things, turns out that Tantric sex plays to the strengths of older people. We aren’t in a hurry. In fact, we’ve had to switch our focus from a quick, hot fire to a slow burn. From intense passion to warm intimacy. From fireworks to steady candlelight.

Tantric practice is all about taking your time and learning to be vulnerable. With Tantra, the journey is the destination.

Dr. Susan Kellogg Spadt, a MiddlesexMD advisor, defines it this way: “Tantric sex originally developed as a form of Eastern yoga practice, the goal of which was to use sexual energy to enter a higher spiritual realm. Although it is an ancient practice, this type of loving has undergone a recent resurgence of popularity.”

The main elements of Tantric sex are a focus on the breath, the alignment and flow of energy (specifically sexual energy), and attention to the partner in the present moment. You’re not in a hurry with Tantric sex, nor are you lost in fantasy world. You’re relaxed and present.

While I’m no expert in the practice, here are a few techniques drawn from Tantric sexuality that might energize your lovemaking.

Prepare the space. Since Tantra is based in spiritual practice, consider the place where you have sex as “sacred.” How would this space look and smell? How would you prepare the environment? Would it feel mysterious or would it be full of light? Would it look lavish or spare and uncluttered? Would it have music or the sound of chimes? Or silence?

You should make it as beautiful and natural as possible. You might have candles or incense burning. You might decorate it with soft fabrics, maybe silks, maybe beautiful tapestries.

MiddlesexMD_LindberghPrepare yourselves. Spend some time decompressing from whatever might occupy your mind. Loosen your muscles, especially those in your jaw, neck, and shoulders. Maybe take a bath so you’re soft, relaxed, and sweetly scented.

Clear your mind of any preconceptions. Expect nothing. You are here with your beloved. That’s all, and it’s enough.

Breathe. Unsurprisingly, breath is central to this practice as it is to many Eastern traditions. Breath releases and directs energy.

In Tantric sex, you breathe in tandem with your partner. Face your partner and breathe deeply, fully, and consciously. Breathe together-you breathe each other’s breath.

Don’t hold your breath or let your breathing become shallow at any time. Concentrate on full, relaxed breathing throughout sex. According to the Tantra, this allows energy to flow unimpeded through your body.

Maintain eye contact. In fact, keep your eyes open throughout your sexual encounter. Breathe together and look into your partner’s eyes. This will probably feel strange and challenging.

Here is an account from a woman who attended a Tantric sex class with a platonic friend who was simply doing her a favor by accompanying her. The instructions were to “think about what this person looked like when they were first born… before they were wounded… what they will look like when they die.”

“Looking into Jeff’s eyes, I felt like I was watching the movie of his life. I saw my friend in a way I rarely see anyone; with all his vulnerability, fear, pain, and joy. It was unsettling but strangely beautiful. I felt cracked open and began to cry.”

If this is the experience of two friends, what might happen between committed lovers?

Get into position. There are lots of Tantric postures, but the one commonly mentioned is the Yab Yum position in which both partners sit erect and the woman sits on her partner’s lap, wrapping her legs around his or her waist. Then, according to Susan Kellogg, “The woman actively rocks forward and back, using her pubococcygeus [pelvic floor] muscles to “milk” her partner’s penis, creating high levels of sexual arousal.”

Don’t hurry. Don’t lose focus. Keep your breathing slow and relaxed. Eyes on your partner. Only tense the muscles you need to use and consciously relax everything else. Be present in the moment. Express what you’re feeling—pleasure, pain, discomfort, joy, connection—either in words or sound, any sound.

Direct your energy. A Tantric saying is, “energy flows where attention goes.” This means that you have control over the flow of energy depending on what you’re paying attention to. If you’re focusing on genital sensation, that’s where the energy goes. But if you pay attention to your entire body, this is where your sexual energy will flow. Powerful, whole-body orgasm is a hallmark of Tantric sex.

Finally, after fully exploring and experiencing this exchange and flow of energy, this intimacy with your partner, according to Susan Kellogg, “Tantric joining… ends when partners, at the point of orgasm, join in a close embrace, usually mouths sealed and fingertips in full contact. Each partner powerfully contracts the pubococcygeal muscles and ‘draws’ orgasmic energy from their genitals up through their pelvis, abdomen and throat to an area in the middle of the forehead known as the third eye that is the center of ‘spiritual enlightenment.’ ”

Not surprisingly, entire books are written about Tantric sex, and larger cities may offer classes on the practice.

Now if you’ll excuse me, I have to stick my head in the freezer.

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From what you describe, you’ve experienced the kind of atrophy that’s very common in post-menopausal women. Without intervention, some estimate that women lose up to 80 percent of their genitals—which is surprising to many of us, just as puberty is sometimes surprising! It’s good to act just as soon as you can, and then maintain the progress you’ve made.

From what you describe, I might recommend that you look at creams or tablets for localized hormones to start. The Estring is inserted for 90 days. Having any foreign body placed in fragile tissues causes irritation or ulcerations for some. But once you’ve achieved a healthy vagina, you could switch from other forms to the Estring, which certainly has a convenience advantage.

Adding estrogen for two to three months will tell you what other actions might be helpful. Along with the vaginal tissues becoming fragile and thin without estrogen, the vagina actually becomes shorter and more narrow. Dilators help to restore capacity, and they’re easy to use.

Congratulations on deciding to reclaim intimacy with your husband! Best of luck, and we’re here if you have questions along the way.

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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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Whether you’re using a cream, tablet, or ring to add localized hormones to your vagina, your partner is not absorbing any—no more than he did when you were producing your own hormones before menopause. You (and he!) can feel perfectly confident about your use of these products, and your intimacy will benefit from the increased comfort you’re likely to experience.

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In the beginning, there was passion. Your feelings were almost painful. You wrote long letters and sent silly gifts and spent hours in whispered conversations on the phone. A lifetime ago. Remember?

Then came the long familiar years. You settled into a cozy, secure routine. You finished each other’s sentences; you knew the next move, the habits, the vulnerabilities, the quirks and preferences.

But what happened to the passion?

Psychotherapist Esther Perel has spent her career studying the sexual language of long-term, committed couples. She’s pondered the dynamics of the love/desire dialectic, and she’s identified the qualities that keep the sexual spark alive over the years. In a recent talk, she discussed her work with exceptional lucidity. You may intuitively know what Perel has to say, but few of us have articulated it so clearly. In any case, it’s good to be reminded—and challenged.

Desire and love are paradoxical. They’re mutually exclusive. Love, says Perel, is to have. It’s associated with security, with safety, with roots and foundations. To love is to know the beloved and to be known. But this contented intimacy isn’t a necessary component of good sex, “contrary to popular belief,” says Perel.

To desire, on the other hand, is to want. Desire craves adventure, novelty, risk. We desire mystery, the unattainable, the 50 Shades kind of guy.

Trouble is, we want both love and desire. We want security and passion. Intimacy and mystery. Safety and risk. So how can these opposing drives coexist in a marriage? How can we settle into the mature love of a long-term relationship without losing the hungry edge of desire that brought us together in the first place? How can we achieve the ideal of a “passionate marriage,” which fans the flame of desire within the intimacy of commitment?

As she studied couples around the world, Perel asked them when they found themselves most attracted to their partner. She heard variations of the same theme:

  1. When they reunite after an absence.
  2. When watching the other from a distance when the partner is completely engaged in an activity. “When I look at my partner, radiant and confident, [is] probably the biggest turn-on across the board,” says Perel.
  3. When there are no demands and no needs.  “Caretaking is mightily loving,” says Perel. But, “it’s a powerful anti-aphrodisiac.”
  4. When there is some novelty or newness. “When he’s in his tux,” said one person. Substitute cowboy boots, or a toolbelt, or motorcycle leather.

In these situations, there is a shift in perspective from the familiar to a sense of separation and distance. It’s the Proustian “voyage of discovery [that] consists, not in seeking new landscapes, but in having new eyes.”

Desire is a dialog we have with committed love. It’s a duet, a dance. The dynamic may be paradoxical, but both are necessary if a long-term relationship is to remain vital. It’s the language of poetry and mystery rather than of process and technique. Desire is more complex than bedroom gymnastics.

From her experience in studying and counseling couples, Perel has distilled several qualities that erotic couples seem to have in common. These aren’t on many “how-to” lists; they have more to do with essence than with activities. They may not be easy to incorporate because they’re not as straightforward as establishing a “date night.” But the concepts she delineates are worth some thought.

  1. Give each other some erotic privacy. Maybe this is the space that preserves mystery. It allows the other some personal freedom to explore. It acknowledges that you aren’t joined at the hip; that there is difference and distance. “Erotic privacy may mean different things to different people,” writes Pamela Madsen, author of Shameless. “It may mean the privacy to look at pornography and not share some desires with our partners. It may mean the possibility of exploring ourselves within agreed upon boundaries without our partners.”
  2. Foreplay isn’t optional. It isn’t a five-minute, pre-sex duty. “Foreplay pretty much starts at the end of the previous orgasm,” says Perel. These relationships cultivate a sense of erotic anticipation.
  3. Check the “good girl” at the door. Desire is selfish. You aren’t responsible for organizing or orchestrating. “Responsibility and desire just butt heads,” says Perel.
  4. Passion has seasons. Like the moon, it waxes and wanes. It will return, but keep on having sex in the meantime. “Willful, non-spontaneous sex,” says Madsen.

“Committed sex is premeditated sex,” says Perel. “It’s willful. It’s intentional. It’s focus and presence.”

To hear Perel’s talk in its entirety, visit the TED website here. This twenty minutes may be the best gift you could give your relationship today.

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A burning sensation in the vaginal and vulvar area can be a symptom of vulvovaginal atrophy, which occurs as estrogen levels decline. Premarin cream or other localized estrogen can reverse those atrophic changes; it typically takes weeks of use for full effect.

If the burning sensation is in or extends further back, toward or including the buttocks, it’s likely not vulvovaginal atrophy. It could be, instead, a nerve condition. Shingles, unfortunately, can happen in this area; there are other pelvic floor conditions—like scarring or injury—that can affect nerves. A careful pelvic exam can help to determine exactly what’s happening.

I encourage you to talk to your health care provider—and again, if you’re not seeing improvement!

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