Archive for September, 2013

Here’s the scene. A “mature” couple is sitting companionably together in the living room, reading. He looks over the top of his paper.

“Hey, Snookums, you look remarkably fetching tonight. Want to get to bed early?

She, thinking: Oh, lord, he hasn’t seen me naked since I gained the last five pounds. Fat on top of cellulite. Saggy bags over saddlebags. “Well. Hmmm. Just let me finish my… knitting. I have to finish my knitting. Then I’ll be right in, honey.”

He, thinking: Yeah, knitting. Bet she’d be ready to jump the bones of some musclebound hunk with hair instead of a bowling ball and a six-pack instead of a whale gut.

And what he does not dare to articulate even to himself is whether she might also be left unsatisfied with his, um, slightly spongy and not-so-reliable accoutrement.

So they sit, each in his or her own corner, licking the wounds of engrained insecurities and missing out on the sweetest years they have left together. All because they misinterpreted each other’s insecurities because they were so completely snowed under their own.

The song may be different for each of us, but too often, the dance is the same.

Body image is powerful no matter what side of the gender gap you fall on. And while men rarely discuss their insecurities, in one study, 38 percent of men would sacrifice a year of their lives for the perfect body—a higher percentage even than women, according to this article in the Guardian.

“These findings tell us that men are concerned about body image, just like women. We knew that ‘body talk’ affected women and young people and now we know that it affects men too,” said Dr Phillippa Diedrichs, who conducted the study of almost 400 men in Great Britain.

While women focus on losing weight, men obsess about losing muscle. While women struggle with vaginal dryness, men struggle with losing their ramrod hardness. While women worry about their stomachs, thighs, and boobs, men worry about their stomachs, muscle tone, baldness, and man-boobs (moobs).

Blame the media. Blame your mother. We’re old enough now to identify and grapple with our own insecurities. And to get over them, already.

No matter how good you look, you’ll eventually become invisible in a culture that is focused on youthful beauty. In her poem I Met a Woman Who Wasn’t There, Marge Piercy writes:

The CIA should hire as spies
only women over fifty, because
we are the truly invisible.

This makes some women feel free and unburdened, and it makes others desperate to turn back the clock, fueling the cosmetic surgery industry, which has grown 77 percent in the last ten years, according to a 2012 AARP article. For their part, men may turn to Rogaine and Viagra and red convertibles—and cosmetic surgery, but in the end, we all—men and women—have to make our peace with growing old.

Because that train is coming, like it or not. And it’s a whole lot nicer to ride out the last adventure of our lives in the same berth.

Here are a few ways to do just that:

Send your body some luv: “The mind is the most powerful beauty tool in your makeup bag,” writes one woman.

Stop the negative chatter, says MiddlesexMD advisor, MaryJo Rapini, who writes frequently about body image issues. In this blog post, MaryJo lists 15 things you should say to your body, such as: “You are my body, and I claim you, and I will take care of you.” And: “I love the way you make me distinguishable that someone can recognize me by my voice, my eyes, or the gait of my walk.”

Do sensual things for yourself and with your partner: Have a massage. Luxuriate in a scented bath. Go all out, if you can, with a week (or a weekend) at a spa. When your body is touched respectfully and sensually, it helps you to remember how good it feels.

Have more sex. The more you have, the better—the more sensual and sexy—you feel.

“Give yourself over to the pleasurable experience and sensation of sex itself, drawing on the depth of your emotional connection with your partner. Issues with physical imperfections can melt away in the face of this focus on mutual sharing of pleasure,” suggests this article from the North American Menopause Society (NAMS).

Keep your body healthy and moving. Forget about looking young. Focus on being healthy. “Consider exercise and weight loss as aphrodisiacs,” says the NAMS article. “Exercise is like Miracle Gro for your brain and body,” says the AARP.

Get the picture? As you age you simply will not feel good about yourself unless you exercise moderately and eat healthfully. Exercise helps keep blood flowing to your brains and keeps your joints lubricated, not to mention keeping your muscles toned, strengthening your bones and boosting your immune system.

What are you waiting for? Get off the couch.

Be gentle with each other. It will just take longer for your man to get an erection, and it doesn’t have anything to do with his attraction to you. And he needs to understand that you’ve been conditioned since childhood to believe that youth equals beauty. You need to hear that he still finds you irresistible.

If you have a same-sex partner, you’re looking in the mirror at your mutually aging bodies. Make sure you each know that’s okay.

As Dr. Eleanor Hamilton, author and sex therapist, writes in this beautiful article, “They both need to reassure each other that their love and the intimacy they share and the long years of increasing trust that has built between them are far more important ‘turn-ons’ than the young, sleek, over-eagerness of youth.”

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Autumn can be a tremendously busy time of year when work ramps up and social obligations resume. Or it can herald a return to peaceful calm after summer frenzy.

Full disclosure: There’s nothing peaceful about autumn for me! My appointment calendar is booked solid. No fewer than three healthcare conferences are on MiddlesexMD’s schedule in the next five weeks. That’s almost a rockstar schedule! (Well, maybe an aging rock star.)

So, whether your summer is an interlude or a frenzy, autumn is nonetheless an opportunity to reevaluate your relationship, sexually speaking, and recalibrate your sizzle, if necessary.

Long-term relationships have two (at least) universal pitfalls. One is boredom; the other is neglect. Occasional boredom is the almost inevitable result of familiarity and routine. It’s the same-old, same-old. It’s our guy in oversized sweatpants with a three-day scruff; it’s us in our stained muumuu and uncombed hair. And it’s the sexual routine that is as exciting as day-old coffee.

Hard to recall those days when we could hardly wait to rip the clothes off each other, hey?

Add a stressful job, social obligations, aging parents, kids in high school or university, and the absolute last thing on our minds is sex. The first thing is sleep. So, maybe we don’t even know if we’re bored because our sex life is over there in the corner gathering dust.

“As therapists, we can vouch for the fact that when people get out of the habit of loving in a sexual way, it can be extraordinarily difficult to get back into it,” writes therapist Christine Webber and Dr. David Delvin in this article.

Your assignment, should you choose to accept it, for this autumn is to reinvigorate romance, and ultimately, your sexual relationship with this person who, once long ago, made your heart beat faster.

Notice that there’s a hint of obligation here. A robust sex life might begin with spontaneous combustion, but it requires regular and conscious refueling to keep the flame alive over the long haul.

So, the first step is to want to revive your sexual relationship badly enough to make the effort and to commit to tending the flame. Here are some tips to get started.

Anticipation is a powerful aphrodisiac, and it’s one of the first casualties of a long-term relationship. “…living together…can take the anticipation out of sex. And anticipation is not just utterly delicious in itself; it’s a useful tool for heightening your passion during the act—when you finally get to it,” write Webber and Dalvin.

You can heighten anticipation by:

  • Scheduling sex. Put it on your calendar—both of you. Then you can begin to prepare—and fantasize—in advance. What will you wear? What will you do? What senses will you pleasure: what tastes, scents, textures might you incorporate? Will there be surprises? Maybe new toys? Maybe you’ll discover a new position to experiment with?
  • Prepare for your date night. Take a fragrant bath. Shave. Moisturize. Scent. Clear your mind of distractions, stress, and worry.
  • Send sexy notes. Leave them in odd places. Describe what you’re going to do to him or her. Sext like the bad girls. Email. Keep sex on the brain during the ho-hum (or hectic) work day.

One woman writes: “My husband resisted getting a cell phone for years. After becoming a small business owner, he finally caved and bought one. …After I had sent him a couple of steamy texts, he came home and said, ‘Boy, I never thought I’d say this, but I sure love cell phones!’ ”

  • Become foreplay aficionados. Nothing builds anticipation like foreplay. And you need a lot more these days, anyway. So, take your time. Tease. Play. What’s the rush?
  • Abstain. Forbidden fruit is always sweetest; the anticipation makes it so. You can touch, kiss, pet, cuddle—but no intercourse until some agreed-upon future moment.

Play. You’re only limited by your imagination here. Your date night could involve a variety of role plays: Arrange a tryst at a local bar. Arrive separately and “meet” each other. He (or you) might have conveniently reserved a room nearby. Go to a romantic movie separately and meet in the back row—make out just like you used to.

Here’s a list of adult games for both spice and romance, and honestly, they sound like fun!

Do it his way. Focus totally on pleasuring your partner. Do exactly what he wants—even if it’s not your cup of tea. Your task is to lovingly provide unforgettably erotic experience. Plan to fill in the gaps in case your partner’s imagination runs dry.

Next time it’ll be your turn.

Change it up. Nothing beats boredom like a change of pace. Try different times—lovemaking in the morning, an afternoon delight. Do it in unfamiliar, maybe even [slightly] dangerous, places—on the floor in front of the fireplace, in your back yard at night, in the bathtub.

Get away—or stay at home. It’s always fun to make reservations for a weekend getaway—a nice hotel with an in-room Jacuzzi. Dinner by candlelight. A sexy, maybe erotic, film. Room service breakfast in bed.

But it can also be delicious to spend a weekend away—at home. Clear your calendar. Turn off the electronic gadgets. Get the cleaning and laundry done ahead of time. Stock up on luxurious and tasty treats that may also be known for their quality as aphrodisiacs.

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Many women go through menopause with little more than irritability and hot flashes. In our last blog post, we reviewed research that suggests, though, that if you’ve experienced postpartum depression or hard-core premenstrual syndrome, you may be at higher risk for depression during perimenopause or menopause. Awareness and perhaps some preparation for this challenging transition might be prudent. It’s like an athlete training for a race. You want to be in shape before you hit the tarmac.

And even if you’ve never had a down day in your life, some commonsense lifestyle adjustments as you approach your “window of vulnerability” might ease the transition. What you absolutely do not want is to be taken by surprise at the intensity of your emotions, as this couple, tragically, was.

Forewarned, as they say, is forearmed.

So here are some suggestions for greater awareness and healthy lifestyle changes that, honestly, are never too late (or early) to adopt:

Nutrition. Eating sensibly is a good foundation for the inevitable metabolic changes that happen during menopause. Go heavy on whole grains and fresh fruits and veggies, ideally from local, organic sources. Lighten up on fats and sugar. Take your vitamins.

If you need to lose some serious weight, now’s the time to get serious about it, before menopausal changes really kick in.

Get moving. Lack of social connection and daily activity intensifies a sense of isolation and lethargy. Create a routine of exercise and involvement. Volunteer for a few organizations you believe in or enjoy. Exercise regularly. Get outdoors—don’t just walk from house to car. Surround yourself with healthy activity and people you like.

Explore treatment options. Some studies indicate that, for perimenopausal depression, hormone replacement therapy, sometimes in conjunction with antidepressants, can ease the mood swings, hot flashes, and insomnia, especially during the early stages of menopause.

St. John’s wort may also relieve mood swings and anxiety during menopause. (But don’t take any natural remedy without talking to your doctor first.)

Build your network. It’s comforting to know that people you trust have your back. And it’s a lot easier to find helpers before you’re in the thick of things.

Maybe find a therapist you like. Maintain connections with good friends.

And if you find yourself overwhelmed with feelings of unworthiness, or are unable to get out of bed or to function normally, for heaven’s sake, tap into that support system. Call your therapist or doctor. Call someone you love.

Menopausal depression is treatable and usually resolves itself once you’re through the change. Then you’ll be back to your sunny, even-keeled self.

In the meantime, it’s just your hormones talking.

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We’ve talked about depression during menopause. It’s a common, joy-sapping beastie that rears its ugly head during this time of whacked-out hormones and middle-age adjustment.

After all, what with hot flashes, insomnia, loss of libido, mood swings, who wouldn’t feel depressed?

While we may not exactly sail through menopause, most of us make it through “the change” relatively unscathed. But for a few, the hormonal fluctuations that may precede menopause by a number of years is part of a larger picture—sort of a déjà vu experience that we ought to be aware of so as not to be blindsided by it.

Episodes of depression are common, and they are more common for women than for men. About 20 percent of women—one in five—will experience major depression at some point in life, and that’s twice the rate at which men become depressed, according to this report in “Dialogues in Clinical Neuroscience.”

Why this happens is unclear, but one obvious culprit is the normal hormonal fluctuations that occur at predictable points in a woman’s life: puberty, menstrual cycles, childbirth, and menopause. Some women appear to be more sensitive to these hormonal changes, and depression—sometimes crippling in its intensity—can result. These predictable points at which female hormones are on a roller coaster may be considered “windows of vulnerability.”

Perimenopause—the years immediately preceding active menopause—seems to be the point at which depressive episodes are more frequent. Even before a woman’s menstrual cycle is changing, her hormones may be dancing the rhumba. Perimenopause can last for five years, on average, and 95 percent of women enter it between the ages of 39 and 51.

“These periods are not only marked by extreme hormone variations but may also be accompanied by the occurrence of significant life stressors and changes in personal, family, and professional responsibilities,” writes researcher Claudio Soares in this report for Biomedcentral.com.

The thing to be aware of, however, is that the biggest predictor of perimenopausal or menopausal depression is a prior episode of depression. And the “reproductive life cycle event” most strongly correlated with perimenopausal depression is postpartum depression—the “baby blues.”

“We also found, however, a correlation between perimenopausal mood ratings and ratings at other reproductive cycle events, especially between perimenopausal depression and postpartum depression,” write the authors of this study published in the Journal of Clinical Psychiatry. “This suggests that there may be a subgroup of women who have a specific vulnerability to developing reproductive cycle event–related depression.”

Other well-regarded studies have confirmed these correlations.

What this means for you, as you head into your final and very challenging “reproductive life cycle event,” is that if you’ve experienced postpartum depression or hard-core premenstrual syndrome, you may be at higher risk for depression during perimenopause or menopause.

In fact, if you’ve had one prior incident of depression, your chances of having another are one in two (fifty percent). If you’ve had three previous depressive episodes, your likelihood of experiencing another is 95 percent, according to The Massachusetts Health Study cited in this report.

But that doesn’t mean you’re without resources: Forewarned, as they say is forearmed. In our next blog post, we’ll talk about what you can do to increase awareness and keep yourself healthy—in body, heart, and mind.

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Overall, estrogen is helpful to libido and sexual desire. Oral (systemic) estrogen can have the unintended effect of decreasing testosterone, which is linked to libido in women as well as men. The reason is complicated, but has to do with liver metabolism and a binding protein that reduces circulating testosterone.

The approach I take with patients is to use non-oral, transdermal (systemic) estrogen, which bypasses the liver and therefore doesn’t affect testosterone levels. I’ve had patients who couldn’t experience orgasm on oral estrogen but could with non-oral estrogen.

And for some women, I do consider adding testosterone. There isn’t a product for women, so I use a very low level of male testosterone “off-label” and then monitor blood levels during use. Sometimes, as an alternative, Wellbutrin (buproprion), an anti-depressant, helps restore libido by affecting the neurotransmitter dopamine.

I’m afraid we women are complicated! There are, though, a number of options to experiment with until you’ve achieved the sex life that makes you happy.

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Why Menopause? Ask Darwin.

Pity the poor chimpanzee. She lives scarcely 40 years in the wild, bearing young the entire time. She is fertile throughout her lifespan, growing old and gray while birthing baby chimps to the end of her days.

That’s just the way things are in the natural world. Only a couple kinds of whale—and human women—live beyond their years of fertility. This is because the evolutionary purpose of a species is to procreate, according to natural selection. If you’re not furiously making babies, you’re hogging precious resources, and if that state of affairs persists, you just may be relegated to the dusty Darwinian basement of interesting but extinct species.

Yet, human women can expect decades of life after fertility. And you can bet that evolutionary anthropologists are having a heyday with this nugget. “Human menopause is an unsolved evolutionary puzzle,” write the authors of “Mate Choice and the Origin of Menopause” in the June 2013 issue of Computational Biology.

Long age, scientists thought that women experience menopause simply because they run out of viable eggs. The ovaries are stocked with a finite number of eggs, as opposed to sperm, which is continually regenerating. Women’s reproductive systems last 30 to 40 years and then the ovaries fail and the eggs run out. The explanation for continued survival beyond menopause was a mystery.

A more recent view suggests that the difficulty and danger inherent in birthing human babies (large neonatal head size relative to the space in our upright-walking pelvis) along with the many years our helpless spawn require before they are able to hunt and gather on their own (not counting the cost of hockey gear and college tuition) are partly responsible for menopause and an infertile older age.

According to this view, it makes some evolutionary sense to limit the years of fertility so a human mother could focus on rearing the children she has instead of taking on the risk of having more children that she might not live long enough to see into adulthood. In other words, quality trumps quantity.

“There may be little advantage for an older mother in running the increased risk of a further pregnancy when existing offspring depend critically on her survival,” according to “The Evolution of Human Menopause,” a report by a pair of researchers at the University of Newcastle.

Then came the Grandmother Hypothesis. This theory emerged from the work of anthropologist Kristen Hawkes, at the University of Utah. In her study of the Hadza, an indigenous tribe in Tanzania, she observed that the tribe’s ace-in-the-hole with regard to survival was the grandmothers—the older, infertile women. These industrious gals spent their days foraging for food, which they distributed among the mothers and children. The grandmothers were a resource that assured not only survival, but also robust health for the Hadza’s most vulnerable members.

The Grandmother Hypothesis suggests that, given the rigors of rearing children, older, infertile women play a critical role in helping assure the survival of their children’s offspring. Those of us who have spent a month—or more—helping out after the birth of a grandchild know there might be something to this. An experienced caregiver in the household who can cook and clean and who just happens to love that new little bundle to pieces makes a huge difference. Plus, she’s free.

These theories may provide parts of the answer to the reason for menopause, but recently a team of researchers from McMaster University in Hamilton, Ontario, published the findings of yet another hypothesis in Computational Biology.

Ready for this?

Men are the cause of menopause, and specifically, their preference for younger women. After generations of being chucked for the spring chicken, so the theory goes, older women developed genetic mutations that selected against fertility but not against longevity. Thus, men remain fertile throughout their lifespan, while women go through menopause. Because apparently, fertility is wasted on us older hens.

But those rabble-rousing researchers didn’t stop there. Next, they tweaked various parameters of the mating preference paradigm with varying results. When the model allowed men and women to mate without regard to age, both genders remained fertile throughout their lifespan.

But when the computer models were adjusted to account for male preference for younger women, Voilà! Menopause. Older women gradually became infertile.

“If women were reproducing all along, and there were no preference against older women, women would be reproducing like men are for their whole lives,” says Rama Singh, an evolutionary geneticist and co-author of the study in this article in Science Daily.

You know, ladies, I think we owe those cradle-robbing men a debt of gratitude. Annoying as it may be to inevitably become the losers in the marketplace of youth and beauty, can you imagine having children in your 80s? From that perspective, menopause never looked better.

And never fear. Natural selection evens the score—on the computer models, at least. When our intrepid scientists adjusted their computers to create a female preference for younger men, then the old geezers lost their fertility, too, experiencing a male menopause just like ours.

Poetic justice, perhaps?

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