Archive for June, 2013

In my line of work, I’ve looked at a lot of lady-bottoms, and I can tell you that “normal” female anatomy is extremely diverse. We are each as unique “down there” as we are in every other body part, and, mostly, it’s all normal. (See for yourself. Check out images of this art installation titled “The Great Wall of Vagina.”)

So the recent buzz about “vaginal rejuvenation” has me befuddled. Why have women suddenly become so self-conscious and discontented with the way their genitals look? So much so that a new subspecialty of cosmetic surgery promises to nip and tuck, neaten and tighten all for the sake of a “comfortable, athletic, petite look,” according to a well-known cosmetic surgeon.

The procedure, called a labiaplasty, reduces or tidies up the labia minora (the inner lips surrounding the vagina), creating a smooth “clamshell” appearance. Sometimes the labia minora is removed altogether. This is called a “Barbie.”

But that’s not all. Cosmetic surgeons can tighten the vaginal opening, tweak the outer labia, reduce or remove the clitoral hood, or perform a little G-spot enhancement.

For the most part, these procedures are done for the sake of appearance. Some practitioners say their patients sometimes enjoy greater genital sensitivity, but no science supports these claims. In fact, surgery always carries a risk of infection or nerve damage, which could actually reduce sensitivity.

Plus, botched labiaplasties are not uncommon. “The problem with this surgery, frankly, is that it looks easy, but there’s a lot of finesse involved,” said a plastic surgeon who specializes in the procedure in this article. “If you don’t know those nuances, you’re going to have dog-ears, or complete removal of the labia when that’s not what’s requested.”

Another specialist estimates that 20 percent of his business involves fixing work that other practitioners messed up.

None of the surgical procedures to achieve a designer vagina are endorsed by the American College of Obstetricians and Gynecologists, or even by the American Society of Plastic Surgery. Both professional groups are cautious about supporting an untested and unnecessary procedure.

Now, the distinction between reconstructive surgery and cosmetic surgery is important. Some women need surgery to fix functional problems like incontinence or to mend genetic defects like vaginas that are short, malformed, or missing altogether. And some women need labial surgery for physiological reasons.

But most women who seek “vaginal rejuvenation” do it to feel better about how their genitals look.

While cosmetic genital surgery is far less common than breast augementation, it has recently hit the radar as the next body part in need of perfecting. Some social commentators (and some women) say that the porn industry is setting the standard for how a woman “ought” to look.

And that look has become increasingly pubescent—hairless, small, and “neat.” Just like the photos of genitalia in girlie magazines. Which, just so you know, aren’t what normal women look like.

“It’s a concerning situation,” says Cheryl Iglesia, a specialist in reconstructive pelvic surgery in this article for Guernica. “A lot of women are being duped by the media and by unethical doctors who are preying on their insecurities.”

And why, I wonder, does it take a surgical procedure (or several) for a woman to like the most intimate part of her body? Does looking like a porn star—or like your girlfriend—create confidence?

I suspect that many of us have made our peace with the way we look and with the inevitable changes wrought by time. But cultural messages are powerful. They can catch us off-balance at times of transition. Certainly, they affect our daughters and granddaughters.

And that’s worth thinking about.

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This is a common question; unfortunately, it’s complicated to answer. First let me say that while I know weight gain affects many women’s sense of being desirable, what I read and my own informal research suggests it’s rarely an issue for their partners (some of whom are, in fact, oblivious—in a good way—and just as attracted as ever).

There does seem to be a physiologic drive to deposit fat during the menopause transition. The theory is that fat produces estrogen (estrone—a relatively weak estrogen), so in the presence of impending organ failure (menopause) and loss of estrogen from the ovaries (estradiol-the major, more important estrogen) that will occur, the body does its defensive thing: It deposits fat, really efficiently and effectively.

Unfortunately, estrone doesn’t provide many favorable effects. The major location for depositing fat is the midsection. Women who have yo-yoed in weight over the years seem to struggle more; those fat cells seem to remember readily how to deposit fat. Even women who have no weight gain during this transition will have a waist circumference increase of up to two inches.

Minimizing the weight gain starts with maintaining a healthy weight over time; those who are most successful in this transition benefit from years of stability at a healthy body weight leading into those years.

Those menopause transition years will be an added challenge, so start to make small healthy changes early on. Women lose muscle mass quite readily at this time of life, so work to maintain or gain muscle with strength training activities.

It’s a fact of life that at this point, it takes more effort to get the same results, requires more dietary caution and exercise, and leaves little room for not paying attention. My motto: You’re now high maintenance; behave like it!

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Ever since Flibanserin was shelved after FDA rejection, the search for the next drug to treat lack of libido in women has been mighty low-key. To be sure, there were legitimate concerns about Flibanserin’s effectiveness, but as I’ve said before, we need more treatment options for women who suffer from hypoactive sexual desire disorder (HSDD).

Now, three years later, initial trials on another pink Viagra drug, which are actually two drugs (Lybrido and Lybridos), are just winding down. The results look “very, very promising,” according to Adriaan Tuiten, the drugs’ developer. If all goes well in the next phase of clinical trials, a pink Viagra could be on pharmacy shelves by 2016.

And that would be something to celebrate.

As I mentioned in my last post, HSDD is common; it’s complex; and it has confounded therapists and researchers for decades. Unlike pills for erectile dysfunction, low libido in women isn’t just a matter of hydraulics—increasing blood flow to the genitals (although it’s partly that).

Therapists and physicians have debated long and hard over female sexual desire—what creates it; what kills it; even what it is. Sexual desire probably has as much to do with our brains and our emotions as it has to do with our plumbing. And, possibly, desire may even be connected to the way women are hard-wired for sex, commitment, and monogamy.

It appears that women like novelty maybe even more than men. And while women don’t tend to be more promiscuous than men, they do tend to fizzle out, sexually speaking, more quickly and persistently within long-term relationships. They just lose interest.

“Sometime I wonder whether it [HSDD] isn’t so much about libido as it is about boredom,” says Lori Brotto, a therapist who has worked extensively on female libido, in this article in the New York Times magazine.

It’s also about loss of hormones that we experience—right about now.

This doesn’t mean that women who suffer from loss of libido don’t love their mates. It doesn’t mean that they can’t become aroused or even experience orgasm. It does mean that the sexual attraction, the heat and fizz, the interest in being sexual has waned or disappeared.

You know, the old “not tonight, dear. I have a headache” routine.

Every night.

Make no mistake, for many women this is a real heartbreak. “How much easier it would be if we could solve the problem by getting a prescription, stopping off at the drugstore and swallowing a pill,” writes Daniel Bergner, author of the forthcoming book What Do Women Want?

This next frontier may be attained if Tuiten’s sister-drugs for HSDD —Lybrido and Lybridos—continue to be as effective as early trials suggest.

The two drugs affect three chemicals thought to be involved with sexual desire and arousal in women: testosterone, dopamine, and serotonin. But each drug takes a slightly different approach.

Both have a testosterone coating that melts in the mouth and enters the bloodstream quickly. Lybrido then works something like Viagra, increasing bloodflow to the genitals, which may heighten a woman’s awareness of her own arousal, releasing a resultant cascade of dopamine, the neurochemical of passion, in the brain.

Lybridos, on the other hand, use an anti-anxiety drug, called Buspirone, instead of the Viagra look-alike. After the testosterone rush, Buspirone temporarily suppresses the production of serotonin, a “higher order” neurochemical that creates feelings of well-being and self-control. Squash the voice of reason (serotonin) and perhaps passion (dopamine) will gain the upper hand. Or so the thinking goes.

Preliminary results from these trials were recently published in The Journal of Sexual Medicine. The next round will involve a much larger study.

“Perhaps the fantasy that so many of us harbored, consciously or not, in the early days of our relationships, that we have found a soul mate who will offer us both security and passion, till death do us part, will soon be available with the aid of a pill,” writes Bergner in the Times article.

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Libido is a tender blossom. A cold blast of hormonal change. A whiff of illness or the wrong medication. Even routine and long-term sexual ho-hum can cause libido to wither like a sweet pea on a frosty morning.

The whole notion of female sexual desire and what causes it to bloom or to die on the vine isn’t well understood (like a lot of female sexuality, actually). But low libido in women is extremely common, according to the few studies done on it. Low libido conservatively affects between 8 and 12 percent of older women—those of us who are in the midst of or beyond the “change.” Other experts say that all women experience low libido at some point in their lives, and I wouldn’t quibble with that statement.

It even has a not-very-sexy name: hypoactive sexual desire disorder (HSDD).

To be clear, the textbook definition of HSDD goes like this: “a deficiency or absence of sexual fantasies and desire for sexual activity. The disturbance must cause marked distress or interpersonal difficulty.” (My italics.)

In other words, it ain’t a problem until you (or your partner) say it’s a problem. Low libido isn’t a disorder per se unless it’s making you or your partner feel distressed, dissatisfied, guilty, or otherwise unhappy.

Interestingly, while sex drive does tend to diminish as we age, most older women are less distressed about it, “resulting in a relatively constant prevalence for HSDD over time,” according to this report by Dr. Sheryl Kingsberg, a friend of MiddlesexMD.

To some extent, women expect to lose their sexy juice after a certain age because that’s what our American culture tells us to expect, according to Mary Jo Rapini, a therapist and MiddlesexMD advisor in an article for FoxNews. Older women aren’t expected to be sexy. They’re expected to be invisible.

Yet, says Mary Jo, women shouldn’t passively accept this state of affairs just because they’re reaching midlife. “Accepting low sex drive because you’re getting older is the same as accepting drugs to control your diabetes when you could change your diet, exercise, and lifestyle regimen.”

For many women, however, low libido is a problem, causing all kinds of guilt, distress, and relationship disturbance, which may either be intense and unrelenting or intermittent and mildily distressing.

If good sex is correlated with general sense of well-being and higher quality of life and self-esteem, it’s not surprising that ongoing sexual frustration can negatively affect health and well-being. Dr. Sheryl mentions several studies that associate HSDD with health problems. In one such study, for example, “women with HSDD experienced large and statistically significant declines in health status, particularly in mental health, social functioning, vitality, and emotional role fulfillment.”


HSDD can be caused by a whole bunch of physical conditions, ranging from certain medications to certain illnesses to, yes, age-associated hormonal changes. But many women struggle with HSDD because of emotional issues, and that’s the focus of Mary Jo’s article. In her experience, the emotional causes of low libido are often relied to stress, relationship and intimacy issues, or to problems with self-esteem and body image.

“Addressing the emotional causes of low libido should be the first step you take in addressing why you no longer desire sex, your partner, or your intimate life,” she writes.

Mary Jo suggests some honest exploration, perhaps with a therapist, to get at the root of these emotional problems:

Are you stressed or depressed? Are you struggling with self-esteem or poor body image? Do you feel emotionally connected to your partner? Can you talk about sexual issues? Is there a history of abuse or infidelity in your relationship?

As with so many sexual matters, the causes of HSDD are complex, intertwined, and challenging to unearth. The cause could be as straightforward as adjusting a medication or as difficult as changing an unhealthy lifestyle or honestly assessing emotional issues.

If loss of libido is troubling you, tackling the underlying causes may also be a journey toward greater overall emotional and physical health, because just as sexuality is woven into the very fabric of emotional and physical well-being, you can bet that what affects sexuality is also affecting other parts of life as well.

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I’ve blathered on about safe sex before. Several times, in fact. I’ve also pontificated about the risk of unexpected pregnancy at midlife.

So why am I beating that same, tired drum again?

Because it’s so darned important, that’s why.

The North American Menopause Society (NAMS) just published yet another study reviewing the sobering uptick in STIs—sexually transmitted infections—in women at midlife and advising physicians to discuss the issue with their older female patients.

That’s what I’m doing here.

This latest NAMS study confirms what we all know experientially—that many of us suddenly find ourselves single again at midlife due to death, separation, or divorce. That we are still sexual creatures and want to be sexually active. But also that we tend to be more vulnerable to sexually transmitted infections and surprise pregnancies for several reasons.

Reason #1: When we reenter the singles scene after a long hiatus, we tend to be less assertive and more naïve. We don’t know the lingo or the rules of the dating game. We may also be unaware of how widespread and ferocious STIs are these days and of how to protect ourselves. After all, we haven’t had to think about prevention in a while. In this case, what we don’t know really can harm or even kill us.

Reason #2: Men are able to have sex later in life now due to erectile dysfunction drugs, thus creating a greater pool of potential sexual partners, according to the NAMS study. This isn’t a bad thing, necessarily, as long as everyone is being careful.

Reason #3: Loss of estrogen and the resultant thinning and drying of genital tissue makes us particularly susceptible to infection. Tiny tears and thin tissue along with a generally less acidic environment puts an older woman at greater risk of infection than a younger woman with healthy, intact vaginal tissue. Sorry, ladies, that’s just how it is.

Reason #4: If we do contract an STI, we may end up sicker than a younger woman. The NAMS study referred to Danish research demonstrating that women between 40-50 years are more likely to develop cervical cancer after contracting HPV than women aged 22-32.

Reason #5: Then there’s that pregnancy thing. Because of irregular menstrual cycles along with changing birth control options, and perhaps a new relationship status, women over 40 have the highest rate of unplanned pregnancy, second only to women under 24. (C’mon, ladies, we’re accidentally getting pregnant at the rate of 24-year-olds!)

We are also more likely to terminate these accidental pregnancies. Again, according to the NAMS study, “as many as two-thirds of midlife pregnancies are terminated.”

While the NAMS study urges physicians to ask their patients about safe sex practices—and I take that responsibility very seriously—you are also responsible for informing, protecting, and empowering yourself if you’re single and sexually active. And sometimes even if you’re in a committed, long-term relationship.

At the very least, insist that both you and any new partner be tested for STIs before you have sex, and that you discuss the results. Even then, use condoms for six months afterward because some infections, such as HIV, take time to show up.

Discuss your contraception options with your physician. Birth control options change at this point in life, and the guidelines state that you should be on some effective form of contraception for a full year after your last period.

But remember, just because you’re on birth control or no longer fertile, you can still contract an STI. So talk about that with your physician, too.

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