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Archive for February, 2014

I don’t always catch AARP The Magazine, I suspect because I’m still adjusting to thinking of myself as part of their demographic. But the most recent issue contained an article I’m glad I saw: “You’re Old, I’m Not,” a report on an AARP survey on “Aging in America.”

Among the findings are a few you’ll accept as common wisdom: People in their 40s define “old” as younger (63) than people in their 70s (75). As we grow older, we find that the process is “easier than I thought,” that we’re not held back from doing what we want to do. Older people appreciate old-folks humor more than younger folks do.

One section of the results, though, sparked my interest in a different way. There’s a difference by gender in agreement with this statement: “I know I’ll enjoy sex no matter how old I am.” Seventy-one percent of men agreed; only 51 percent of women did. Gender mattered much more than age: There’s only a 7-point difference between people in their 40s (66 percent) and people in their 70s, 59 percent of whom still expect to enjoy sex.

Given my line of work, I take that difference by gender as something as a battle cry. I certainly don’t want women to be like menvive la différence! But I take it as a personal, professional, and generational challenge to see more women look forward to enjoying sex!

I doubt that AARP was able to delve into the thinking behind people’s responses to that question. My guesses about why women are less optimistic than men are based on my years as a menopause care provider, not on AARP’s data. But here are my theories:

First, we’re young at understanding menopause. The average age for menopause is now 50; until 1900, few women lived past that age. We’re living longer now, and have much more experience with menopause, but we have no deep cultural expectation of conversation about it.

And that leads to the second factor: In the absence of good information, the worst-case scenario tends to take over our imaginations. Have you noticed that talk about child birth and root canals nearly always leads to the sharing of horror stories—the labor that lasted four days, the excruciatingly painful dental experience? Even though those stories are the exception, not the rule? I’ve seen the same thing happen with women talking about menopause, and the women who hear those stories are more willing to accept limitations and less empowered to take control of their own sex lives!

There’s one more factor, too: We as women start to receive messages that sex and older don’t compute. For some reason, “sexy woman” conjures a young woman in our media and culture—and, for some reason, we’re susceptible to that suggestion!

I don’t know when AARP will conduct this survey again. But when they do, my hope is that women agree just as often as men that “I’ll enjoy sex no matter how old I am.” Because we can, when we take the time to understand what’s happening as our bodies change. And we want to, when we recognize what sex means to our health, our well-being, and our relationships—and all the ways those intertwine.

And, okay. Because we women can be a little bit competitive, too.

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You may be among the 4 percent who won’t experience orgasm–who, for some reason, simply can’t, under any circumstances. It’s more likely that you’re among the 96 percent who can. When a woman tells me she’s not sure if she’s experienced orgasm, I say she probably hasn’t; it’s fairly obvious when it happens.

Most women need direct clitoral stimulation to reach orgasm; what we see so often in movies, of partners climaxing together through intercourse alone, is rare in real life. Beyond that, there’s plenty of variation: Some women may need an hour of clitoral stimulation; others may experience orgasm through brief nipple stimulation.

I recommend that each woman know her own clitoris, because degrees and types of pleasurable stimulation vary among us. Vibrators are very effective in stimulating the clitoris, and spending time yourself, exploring in a relaxed environment, will help you advise your partner on what feels good. Soothing or arousing music or a sexy scene from a movie can help, too.

When you’re ready to go further, you can try internal stimulation, which leads to orgasm for about 30 percent of us. A vibrator like the Gigi2 can be used both externally and internally, so you can place it in the vagina (use a lubricant to be sure you’re comfortable) and see what happens.

While chances are good (about 96 percent good!), there’s no guarantee of orgasm. And because being focused only on orgasm can actually inhibit your ability to experience it, I hope you’ll enjoy the intimacy and other sensations along the way!

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The loss of estrogen that comes with menopause results in thinning of urogenital tissues, which include the vagina, vulva, and urethra. Because those tissues are thinner, they can be more fragile and susceptible to “trauma.” We don’t think of sex as “traumatic,” but the activity can cause minor tissue damage.

Sex can also introduce bacteria to the bladder via the urethra, which can lead to bladder infections. And either an infection or the inflammation of damaged tissue can lead to the symptom of urinary urgency.

Using a lubricant during intimacy will minimize the “trauma” to tissues. Emptying the bladder soon after sex may flush out bacteria before they can proliferate and become an infection. (Women with frequent urinary tract infections linked to sex sometimes find it helpful to take a dose of oral antibiotic with sexual activity.) And a therapy like localized estrogen or Osphena may help by restoring proper pH and increasing cell layers.

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First, let me assure you that you’re not alone in feeling a loss of libido: It’s common for women to lose desire, even in great, emotionally supportive relationships.

Low desire is challenging to treat, because we women are complex sexual creatures. I prescribe testosterone for some of the women in my practice; about 60 percent of those who’ve tried it have found that it does boost libido. I wish it were 100 percent, but it’s not! And some physicians are reluctant to prescribe testosterone for women because it’s “off-label.”

Given what we know about women’s sexuality, I advise women to engage “mindfulness” when it comes to sex. Often, we feel desire somewhere in the process of being intimate; we may not be driven to intimacy by desire. We need to choose to be sexual! I encourage women to plan for sex, committing to a frequency that is comfortable for both partners. It might be once a week, once a month, on Friday evening or Sunday morning—whenever you’re least likely to be distracted, stressed, or tired. When we have been sexual, we’ve typically found it pleasurable and we’re glad we did!

Finally, you mention being self-conscious about your breasts, which are no longer like they used to be. We are our own worst enemies when it comes to body image, and we pay the price when we rob ourselves of pleasures! I’ll bet your partner doesn’t look like he used too, either, and that he loves every inch of your body, as you love his. You might reread this blog post on body image and try some of the suggestions to “send your body some luv.”

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Shhh No More!

We had a focus group a couple of weeks ago, a gathering of women to check in on what’s on women’s minds. One of the questions we asked was to whom women talked about sex—beyond their partners—and about any sexual health questions they might have. The answers were just as varied as I thought they might be. One woman said she’d talk to a stranger on an airplane—someone to whom she could say, “See you never!” Another woman has a group of long-term friends who she says frequently talk about any part of life—including sex.

I remember sex as a subject of great interest and fascination when I was very young—whispers, conjectures, a lot of mis-information and tall tales. By high school, we knew more, the better informed among us bringing along the uninformed. In college, we received a great deal more detail as data from actual, rather than fictional, experimentation became more commonplace.

It may be marriage that closes our mouths. We may be willing to share exploits or guess at sex before we choose our mates, but once we do, the walls of privacy go up, and silence rules our sexual lives. Or maybe we’re susceptible to the cultural messages that suggest that older women plus sex equals nonstarter. Maybe we’re embarrassed, as we approach and pass into menopause, that we’ve got “symptoms”; we don’t want to become Great Aunt Tessie, who shared her upper-GI details at every family gathering.

I buy the privacy reason, the loyalty to one’s partner. But I reject the cultural messages and the embarrassment. We should allow nothing to get in the way of our opportunities to continue to learn and explore, and to find reliable sources of information and aid when things aren’t working. Because, let’s face it, most of us weren’t trained in sexual techniques—or even anatomy. We need information as we grow and change sexually, and most particularly during menopause, when our bodies, while still miraculous and powerful, are less predictable and consistent.

So, please. Talk. As a reserved Midwesterner, I’m not sure I recommend raising the topic with your fellow passengers on airplanes—but far be it from me to discourage you. Talk to your partner about how your experience is changing. Talk to your friends to compare notes—and recommendations for health care practitioners or websites or books you find helpful. Talk to your health care provider, and be sure s/he is listening. Join us on Facebook or Twitter. Use our Ask Dr. Barb button, front and center on our website; you’ll get a private, personal answer and may inspire a future blog post Q&A.

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Women are not men. No surprise, right? In many parts of our lives, we know that.

When it comes to sex, though, many of our expectations—and those of the experts who advise us—are still based on expecting that men and women are more alike than not. And women are not men.

There’s an important implication from the model for women’s sexuality I’ve shared before, the one developed by Rosemary Basson, of the University of British Columbia. Women are not men: While men quite predictably experience desire and then arousal, women don’t. Sometimes, actually, women don’t experience desire until midway into lovemaking.

No big deal, you’re thinking? I wish.

Unfortunately, the messages we’ve internalized affect the way we behave and what we believe about ourselves. I’ve talked about hypoactive sexual desire disorder (HSDD) before, and it’s something I regularly talk about with women in my practice. There are hormonal changes, reactions to prescriptions, and other factors that can lead to HSDD, which is real and deserves attention from researchers and pharmaceutical companies.

But sometimes what we wish we could fix with a pill is actually the fact that we’re women, not men. If we, as women, expect to respond sexually as men respond, we’re more likely to misread our reality as “lack of libido.”

Which leads to the other reason I think understanding Rosemary’s model is a big deal. I talk to women who are at some point in a vicious cycle: They don’t experience interest as they used to; some physical changes have made intimacy uncomfortable or even painful; they begin to avoid sex; the physical changes continue; and intimacy becomes even more uncomfortable. How do we reverse this sequence? Or avoid the slide into it?

We can start with the reasons—beyond the hormones that drove us at 27—that we might want to be sexually intimate with a partner: to please him, to experience closeness, to cement our relationship, as an apology, a thank-you—or because we want to feel our own liveliness, sensuality, and power!

And then we can trust that desire will come into the picture, if we’re having the kind of sex that arouses us. Michael Castle wrote about this in Psychology Today: “Sex that fuels desire is leisurely, playful, sensual….  based on whole-body massage that includes the genitals but is not limited to them.”msmd-features-368x368_kama_sutra

Castle says women often complain that men are “too rushed, and too focused on the breasts, genitals, and a quick plunge into intercourse.” That kind of lovemaking doesn’t allow space for women to experience desire. He points out, too, that leisurely, sensual sex is also recommended by sex therapists to men dealing with premature ejaculation or erectile dysfunction. Happily, the kind of sex that fuels women’s desire is also good for their partners.

Women are not men. We can recognize, internalize, and celebrate our difference. We can be sure we’ve communicated with our partners what we like when we make love. We can let go of any expectations except our own. We are women.

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