Archive for January, 2014

Breasts play a role in our sexual response, as I’ve described before. Our nipples are bundles of nerve endings that respond to touch. Some women (though not most) can reach orgasm through nipple stimulation alone. Others of us rely on breast and nipple fondling to put them “over the top” in experiencing orgasm during oral sex or vaginal intercourse.

So while breast cancer isn’t central to my focus on women’s sexuality, it’s obviously connected—as the heel bone is to the ankle bone, the ankle bone to the shin bone. And because in my practice, I advise women on many aspects of their health, I pay attention to the discussion about mammograms and breast cancer diagnosis.

It’s complicated, and it’s controversial right now. An article in the New York Times last month previewed a study published in JAA Internal Medicine. Dr. H. Gilbert Welch, of the Dartmouth Institute, concludes that three to fourteen 50-year-old women in 1,000 (that range tells you something of the current controversy about data) will be overdiagnosed and overtreated as a result of mammograms. Zero to three women in that same 1,000 will avoid a breast-cancer death. Dr. Welch encourages more study, but also concludes that mammograms are over-used and ineffective.

That article prompted an almost immediate response from Dr. Elaine Schattner. Dr. Schattner takes issue with the notion that women are overly harmed by false positives. Mammogram technology is “more accurate and involves less radiation than ever before,” she says. Instead of doing more study, she suggests we focus on making high-quality screening facilities available to all women, get really good at accurately reading the images, and let women themselves decide how to manage the balance between risk and reward.

In my own practice, I use the guidance from the American Congress of Obstetricians and Gynecologists, which calls for annual mammograms for best early detection. I balance that with my own knowledge of each woman’s history and risk factors, but it’s still complicated. I might have a patient whose mammogram comes back entirely negative—which is positive!—but still receive a recommendation for further imaging because of family history. The family history might be for cancer detected in a woman in her 80s or 90s.

Cost factors in, too, both individually and collectively. As more of my patients have high-deductible health insurance, the decision about whether to have an MRI is more consequential. And, of course, tests that aren’t necessary or productive are part of what’s driving the cost of health care up for all of us.

And yet! Given where we are with treatment, early detection remains one of our best assets in combating breast cancer. I’m reminded of an earlier paper that concluded that of the study subjects—women from 40 to 49 with stage I, II, or III invasive breast cancer—77 percent who died hadn’t had regular screenings.

As a physician, I’m frustrated by the difficulty we have in sending consistent messages to women. I don’t want women to be afraid of breast cancer, but neither do I want them to be casual or skeptical about screening methods—like mammograms—that are relatively low risk and low cost.

What about you? Are you confused by what you read about mammograms? Do you know what’s recommended for you? Do you follow those recommendations? Are you confident your health care provider is taking you—individually—into account? Have you had to navigate insurance guidance as well as medical guidance?

The worst thing we can do is to throw up our hands and give in to the ambiguity. The best thing we can do is to encourage each other, speak up, demand common sense paths to follow, and work to make screening readily available.

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It’s going on eight years since I transformed my medical practice. I studied and became certified by the North American Menopause Society as a menopause care provider, and while welcoming patients into my practice, used their questionnaire — a thorough document that makes it easy for new patients to give me a comprehensive view of their symptoms and health histories.

On that eight-page-long form there are just a few questions for women to answer about their current and past sexual experiences:

  • Do you have concerns about your sex life?
  • Do you have a loss of interest in sexual activities (libido, desire)?
  • Do you have a loss of arousal (tingling in the genitals or breasts;
    vaginal moisture, warmth)?
  • Do you have a loss of response (weaker or absent orgasm)?
  • Do you have any pain with intercourse (vaginal penetration)? If yes, how long ago did the pain start? Please describe the pain: Pain with penetration? Pain inside? Feels dry?

I continue to be amazed by the responses from my patients. Sixty percent of my patients have experienced a loss of interest in sexual activities, 45 percent have a loss of arousal, and 45 percent a loss of sexual response.

And when I talk to them, they are

  • Perplexed—because they don’t understand what’s changed.
  • Disappointed—because they expected there to be more.
  • Frustrated—because they don’t know what to do about it.

And when you carry those numbers from my practice to the rest of the country–well, more than 44 million women are aged 40 to 65 in the US alone. Some 6,000 of us reach menopause every day. And at least half of us experience sexual problems with menopause. Probably more.

That’s a lot of disappointed women. And a lot of disappointed men, too.

But you know what it means? Those symptoms you think are setting you apart, making you the odd woman out? They’re not unusual. You’d be more unusual if you sailed through perimenopause and menopause without symptoms.

So speak up! Talk to your health care provider about what you’re experiencing. Read sites like ours to learn more about your options for compensating for changes that aren’t making you happy. Talk to your friends and sisters about your experiences.

We don’t give up reading when our eyesight weakens—we snag some cheaters from the drugstore. We don’t have to just accept the changes if we don’t want to. We’re smart, resourceful, and can do what it takes to live the lives we want to live.

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My last blog post, about thinking about sex as we think about exercise to encourage us to keep our sexuality alive, reminded me of another article I saw a while back.

In “Men Don’t Think about Sex Every Seven Seconds,” Dr. Laura Berman set out to debunk the urban legend alluded to in the headline. She cited a study done at Ohio State University, which concluded that men think about sex, on average, 19 times a day; women think about sex about 10 times a day.

That’s a far cry from every seven seconds, which works out to somewhere over 8,000 times per day, if my math is right and assuming eight hours of sleep.

Now, that research was done with college-age men and women, and I’m willing to cross-reference the National Surveys of Sexual Attitudes and Lifestyles (NATSAL), recently completed in Britain, to guess that by midlife, the rate is reduced by as much as 60 percent. For women like me, that means thinking about sex three or four times a day.

I don’t know how that strikes you—as too much or too little! Laura made another comment in her article that resonates with what I’ve seen in my practice: Researchers “found that incidence of sexual thoughts were most highly governed by one’s own sexual belief system. …People who had anxiety, shame, or guilt around their sexuality were less likely to have sexual thoughts, while people who were comfortable and secure in their sexuality were more likely to have sexual thoughts.”

That’s especially important to us as midlife women. We get lots of messages that conflict with the reality that we are still vital, complete, sensual, sexual creatures. As we watch our bodies change—through childbearing, decades, illness, losing and gaining (and losing and gaining) weight, new wrinkles—we ourselves sometimes question whether we are still sexual, attractive to ourselves as well as to our partners.

Dissatisfaction with our bodies is hardly exclusive to us midlife women, sadly. But when it affects what we decide to do or not to do, it begins to matter more to us. You’ve no doubt seen articles about staying active, because the more active you remain as you grow older, the more active you’re able to remain. You keep muscle tone, bone mass, and balance only as you exert yourself.

The same is true of our sexual selves. Physically, being sexually engaged increases circulation to vaginal tissues, which naturally thin and become more fragile as we lose estrogen. It’s equally important that we’re attuned to the mental part of the equation.

Remember Stuart Smalley on Saturday Night Live? The nerdy guy with the affirmations? “I’m good enough, I’m smart enough, and doggone it, people like me.” What if we midlife women had affirmations for ourselves? Could we use them to both reclaim our bodies and nurture our sexual selves?

I’ll have to give that some thought. Possibly up to ten times a day.

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There are many benefits to being sexually active: It releases estrogen and increases oxytocin, serotonin, endorphins, and immunoglobulin A. This chemical and hormonal stew makes us both feel and be healthier. Having sex makes us feel powerful, giving, and connected, all of which feed our relationships with our partners.

I came across a recent study that affirms another benefit I often talk to women about: Sex is good exercise.

MiddlesexMD_CouchThe study was conducted by Antony D. Karelis, who teaches exercise science at the University of Quebec at Montreal. Participants in the study wore armbands while having sex, and also jogged on treadmills to produce comparative data. The results? On the “metabolic equivalent of task” scale, on which sitting still ranks a 1-MET, sex ranked 6-MET for men and 5.6-MET for women. That puts it, according to Gretchen Reynolds, author of “Sex as Exercise: What are the Benefits?” as roughly equivalent to playing doubles tennis or walking uphill. To do your own comparisons, it’s categorized as “moderate exercise.”

Good to know, right? And I think we midlife women can use this knowledge to our advantage. Part of my counsel to women experiencing diminishing libido is to be intentional about remaining sexually active. There are two parts to my rationale: First, as our hormones diminish, we’ve got that “use it or lose it” thing going on that I’ve talked about before. Second, having sex begets having sex. That is, we women will want to have sex more often when we—wait for it—have sex.

There’s a line from the study conclusions that made me smile: “Both men and women reported that sexual activity was… highly enjoyable and more appreciated than the 30-minute exercise session on the treadmill.” I’m so glad to hear that!

So I start to wonder: How can we apply to our sex lives the same thinking that gets us religiously to yoga or Pilates several times a week? Neither we nor our partners want us to be thinking about sex as one more chore on the to-do list or an obligation on our calendars. But can we consider it a gift to ourselves and our health, as we do our morning walk or Zumba class? Will that give us the extra incentive to make the time and the commitment?

I’m hoping so.

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What you describe—pain and a burning sensation around your clitoris—is most consistent with vulvovaginal atrophy. As we lose estrogen, the genital tissues thin, and the labia and clitoris actually become smaller. There’s also less blood supply to the genitals. Beyond making arousal and orgasm more difficult to achieve, these changes can also lead to discomfort, and experiencing pain when you’re looking for pleasure will certainly affect your sex drive and arousal!

Localized estrogen is the option that works best (and it’s often a huge difference) for most of my patients, restoring tissues and comfort. Talk to your health care provider about the available options and what you might consider in choosing one.

A vaginal moisturizer can also help you restore those tissues, but I suspect you’ll find that most effective in combination with localized estrogen.

Please do take steps to address your symptoms! If sex can be more comfortable and enjoyable for you, I’m hopeful that your sex drive will rebound.

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For every reader of a study, there’s a different headline. That’s my conclusion after reading The Lancet’s publishing of the findings from the British National Surveys of Sexual Attitudes and Lifestyles (NATSAL).

I’d been intrigued by an article in The Guardian that suggested Britons are having less sex because of the struggling economy and too much technology. I think either is credible. I agree with Kaye Wellings, of the London School of Hygiene and Tropical Medicine, when she says that “there’s a strong relationship between unemployment and low sexual function [which] is to do with low self-esteem, depression.” And common sense tells me that it’s hard to be aroused by a partner with an iPhone in his hand.

But when I read the full research report, there were other things that spoke to me.

This is the third time the full research has been done, using comparable methods so that trends can be examined over 60 years. And this is the first time that the eligible age range went beyond 44 years—all the way up to 74!

And that’s a very good thing, ladies, because we haven’t stopped having sex just because we’ve passed our mid-40s.

In fact, that one change to the study’s design led to two of their most notable conclusions:

  • That sexual lifestyles have changed substantially in the last 60 years (which sounds elementary, my dear Watson, but they can tell us exactly how!)
  • And that “research into the sexual health and wellbeing of men and women in later life—who now have increasing expectations of sexual fulfillment—and make up a growing segment of the population—is a neglected area.”

Well, yes! And I’m grateful to see conclusions like those from well-respected research projects!

A couple more things struck me as I read through the details, because they resonate with my experience as a menopause care provider. The frequency of sexual encounters does decrease as both men and women grow older; among women 65 to 74, intercourse is happening about a third as often as among women 25 to 34. There is, though, still a variety of sexual experiences among the older women, including oral and anal sex.

I note that men over 55 are more likely to have a partner of the opposite sex than are women at the same age, and yet men of that age are three times more likely to self-stimulate than women are. Now, I know that sexual behavior depends on many things, including social norms and attitudes.

But I also know that women are uniquely “use-it-or-lose-it” creatures. When we’re without partners, we can’t assume that our sexuality is stowed away to be taken out again at some later date. I encourage women to think about self-stimulation, because orgasm is good for us physically and mentally, and it helps us maintain patent vaginal tissues.

Given the numbers, I know it can’t happen for everyone, but I’ve seen enough women find a second love to think it’s worthwhile to maintain our sexual health. Not because a woman needs a man (that whole fish without a bicycle thing), but because sometimes the right woman and man find each other. And it’s a whole lot easier to maintain your sexual health and capacity than it is to reclaim it.

Because data show—British researchers proved it—that “sexual health is a key component of well-being,” even for those of us over 44, and even for those of us currently without partners.

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You say that you’re both excited and anxious about being with your partner, but that you’re tense with him and haven’t experienced this before. Let me first say that there’s no magic pill that will solve this problem.

For women, sharing sexual intimacy requires the ultimate in trusting, giving, and sharing. This emotional component is just one part of a complex whole for women, but it’s the place I’d start. I’m curious about whether you’re tense with this partner in situations outside the bedroom, and whether you’ve been able to express your concern. It would be helpful it it’s a problem you’re looking to solve together rather than a “performance anxiety” issue for you alone. Being anxious about being able to experience orgasm only makes it more difficult!

You might consider seeing a therapist with a focus in sexuality to be sure that you’re clear on the emotions and feelings you’re experiencing.

If there is no emotional barrier to address, I’ve recommended Viagra or a very low dose of testosterone for women who have lost orgasm or intensity; both of these drugs are prescribed “off label,” which means they’re FDA-approved for another use.

I wonder whether you’re able to experience orgasm with self-stimulation; if you haven’t tried, I encourage you to. A vibrator used either alone or with your partner may provide the increased sensation you need. And if you’re able to orgasm alone, you may learn some things about your response that you could share with your partner.

Sex is often complicated, with multiple interdependent components; it doesn’t help that our bodies change as we gain years! Please do look to a therapist for any emotional considerations; if physical considerations remain, a health care provider knowledgeable about menopause can help you evaluate options. Most women in my practice are able to reclaim this part of their pleasure!

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