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Archive for March, 2014

Itchy beyond words. Crotch of underwear rubs painfully against labia. Sensation of being on the receiving end of a vulvar wedgie. Feels like tiny razor blade nicks in my vagina during intercourse without lube or adequate foreplay. Also difficulty with penetration.

Doesn’t that sound awful? If that were you, I wouldn’t be surprised that you’re not thinking about sex. Just as awful, about half of us think that vaginal dryness is something we just have to live with—and about the same number of us are hesitant to raise the topic with our doctors.

The truth is that vaginal dryness does not need to end the intimacy you have with your partner—or the afterglow you experience yourself after sex.

First, a word about what’s happening: Yes, it’s likely hormones. As estrogen levels decline, the vaginal lining changes. It becomes more delicate and less stretchy. There’s less lubrication and less circulation. Vaginal dryness is a typical first sign of vaginal atrophy, when vulvo-vaginal tissues shorten and tighten. It’s common; you’re not alone, and you’re not deficient.

pink 2013.02If you’re just beginning to notice some discomfort, you can take the easy step of adding lubricant to your foreplay. Lubricants come in three types: water-based, silicone, and hybrid. My patients with dryness issues typically like the silicone and hybrid best, because they last the longest without reapplication, and because they seem just a little bit slipperier to some. Lubricants are made specifically for safe use on and in your vagina; if you want to experiment with a few, you can try our Personal Selection Kit (and read more about it here).

Next, you can add a vaginal moisturizer. While lubricants provide temporary comfort, reducing friction during sex, moisturizers work to “feed” and strengthen vaginal tissues around the clock. Moisturizing here is just like moisturizing your neck or your face: You have to be faithful! I recommend application at least twice a week. Moisturizers need to be placed directly in your vagina, which can be done with an applicator or a clean syringe you reserve for that purpose.

For some women, these two products—and the right amount of foreplay—are enough to make a difference. If they don’t do it for you, please talk to your health care provider, even if you think it will be awkward: Your sex life is important! There are localized estrogen products and a relatively new oral medication (called Osphena) that may be helpful for you, but you’ll need a consultation with your physician and a prescription.

This isn’t the end; it’s only a transition, which we as women have a lot of practice with. Take heart and take charge!

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Surely this has happened to you: You read one article, and it leads you to another. From that second article, you’re pointed to another. Before you know it, you’ve spent an hour diving into a topic that wasn’t quite on your to-do list.

Today I’m glad I did. The first article was “A Good Sex Life Can Help Older Couples Cope with Illness and Other Difficulties,” in the Washington Post (a long title, but you don’t have to read the whole article to get the point). That led me to the full research in The Journals of Gerontology. And a reference in the full research prompted me to seek out an earlier article by researcher Adena M. Galinsky, published by the National Institute of Health.

That article, published in 2012, is called “Sexual Touching and Difficulties with Sexual Arousal and Orgasm among U.S. Older Adults.” The author defines “sexual touching” as “non-genitally focused sexual behavior,” including “but not limited to, kissing, stroking, massaging, and holding anywhere from one part to the entirety of a partner’s body.”

This, ladies and gentlemen, is foreplay, and what I love about this article is that it presents empirical data of its importance! With more foreplay, both men and women experienced fewer “difficulties with orgasm, sexual pleasure, and sexual arousal” and more physical pleasure in their relationships.

msmd-features-368x368_kiriWe all have “sexual scripts,” Galinsky says, which we learned growing up and tell us, without our thinking about it, how to be intimate. Depending on where and when you and your partner learned about sex and romance and relationships, your scripts may not include much sexual touching. If that’s the case, it’s time to call “Rewrite!”

Having the time and the cues of desirability, safety, intimacy, and arousal are critical to us in midlife. If we don’t have them and still expect our bodies to respond as though we’re 20, we’re setting ourselves up. And we can fall into the downward spiral I’ve talked about before: We’re uncomfortable or unsatisfied when we have sex, so we’re unmotivated for a repeat performance. Because we’re not having sex, it’s less comfortable next time we try, so we put it off longer. We may begin to wonder if there’s something wrong with us, which is the opposite of feeling sexy. And before we know it, we’ve abandoned a part of ourselves that made us feel loved and lovely and powerful—and our partners quite happy!

You can talk to your partner about a collaborative revision of your “sexual scripts.” You can share this guest post by a “man friend” of MiddlesexMD, or this “Open Letter: How to Really Turn Me On” to start the conversation. And then, you know, one thing can lead to another. In a very good way.

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A couple of weeks ago, I talked about an article I’d seen about how sexual intimacy is linked to marital happiness. The research, by Adena M. Galinsky and Linda J. Waite, found that continued healthy sex-lives help couples dealing with physical illness, especially chronic health problems.

Couples who had sex frequently (and sex was defined broadly—it didn’t need to include vaginal intercourse) were more likely to say they had a good relationship.

MiddlesexMD_WhitmanThis is, of course, a chicken and egg: More sex doesn’t automatically make a relationship good. It’s more likely—and perfectly reasonable—that an unsatisfying relationship will include less sex. And the women I meet through my practice as well as the rest of life show me that this is often a time when our relationships get some re-evaluation.

Sometimes it’s the empty nest, and the change in schedules and priorities that comes with it. Sometimes it’s retirement, for one or both partners, which means a lot more together time. Sometimes it’s the stress of caring for aging parents along with everything else. Whatever the prompt, when some of us look at our relationships, we say, “Is this really what I want?”

So it was interesting to me to read the details of the Galinsky Waite study, to see how they measured the quality of relationships. These are the questions they asked:

  • How close do you feel your relationship with your partner is?
  • How often can you open up with your partner if you want to talk about worries?
  • How often can you rely on your partner for help with a problem?
  • How often does your partner make too many demands?
  • How often does your partner criticize you?
  • How happy is your relationship with your partner?
  • Do you like to spend your free time together, separately, or some of both?
  • How emotionally satisfying is your relationship?
  • How often does your partner get on your nerves?

If you’re feeling some vague discontent, those questions might help you with a conversation with your partner—or with a couples therapist if you decide some outside perspective and coaching would be helpful. If you’re feeling angry, or resentful, or isolated in your relationship, it’s no surprise that you’re not feeling sexy.

And you deserve to.

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I referred a few weeks ago to the controversy surrounding recommendations for the frequency of mammograms. A conversation over the weekend reminds me that there’s a similar fog surrounding the change in guidelines for Pap guidelines, introduced about two years ago and now working its way through health insurance policies.

We used to all take for granted that our annual Pap screen was the centerpiece of our annual physical exam. In fact, many women calling my office for appointments referred to the appointment that way: “my annual Pap test.” And the prevalence of annual Pap screenings did have an effect, lowering the cervical cancer rate in the U.S. by more than 50 percent over the past 30 years, according to the American Congress of Obstetricians and Gynecologists (ACOG).

Current guidelines call for Pap screening every three to five years, depending on your age and other health conditions—and there’s a lot of agreement about that from the American Cancer Society, ACOG, the American Society for Clinical Pathology, and, likely, your insurance company.

But! This doesn’t mean that there’s no need for an annual “well-woman” visit, including a pelvic exam. Exactly what happens at each annual visit should vary according to your age and your health history. What’s common, though, in addition to updating overall health statistics, is a thorough inspection of the vulva and vagina, including palpation of the area, including the lower abdomen, rectal, and bladder regions. We’re looking for any early indication of abnormality, but if your general health is such that you wouldn’t treat a condition if discovered, no further evaluation is necessary. A clinical breast exam is also part of the annual exam.

In addition to the “clinical” part of the exam, though, there are benefits that you can especially appreciate as you navigate perimenopause and menopause. First, your body is changing, so having an annual “date” to check in on your body helps you be aware of what’s happening. When you share your observations with your provider—which I hope you do—they’ll be part of your medical record, which gives you both a view of trends over time. With our busy lives (jobs, parents, kids, grandkids, volunteer projects), without a checkpoint, we can find we’re simply adapting to changes without even being conscious of them.

And the second benefit is that, with regular communication, your health care provider can be a genuine partner in keeping you healthy—physically, emotionally, and sexually. Seeing him or her at least once a year is part of that; the other part is setting the expectation that your appointment includes answering your questions—about everything from your tennis elbow to your vaginal dryness.

If you don’t find that expectation being met, get bossy. An annual exam—and, just as important, the conversation that goes along with it—is part of managing your own health. Having a health care provider with the time, expertise, and patience to answer your questions is not too much to ask. And when you’re comfortable with and confident about your health care provider, you won’t be a stranger.

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I wish there were a “secret sauce” that worked for all of us to restore libido. Not surprisingly, it’s more complicated than that.

It’s somewhat unusual to have an abrupt change to libido; for most women, it’s a “slow drift.” The first thing to consider with a dramatic change is any new or different medications. There are quite a few that have effects on desire: blood pressure, pain, and mood medications (antidepressants) to name a few. If you have had a change, you can work with your doctor to experiment with dosage or medications; let him or her know of this unintended side effect.

You ask about Cialis and similar products. They can help with orgasm (as they do for men), by arousing blood supply to the genitals, but they don’t have an effect on libido or desire.

One option to consider is testosterone. While it’s thought of as a male hormone, it’s also present in women and is linked to libido. Some physicians aren’t willing to prescribe it for women because it’s an “off-label” use, but 60 percent of women report significant improvement in libido with testosterone replacement, and 20 percent of U.S. prescriptions for testosterone are now for women.

The other factor important to consider is mindfulness–which we might also call intentionality. While you may not feel desire that motivates you to be sexual right now, you know your long-time partner does. You can make the decision (together) that you will continue this activity together, including foreplay. (And I note a recent study that linked frequency of sexual activity with the quality of relationships, which confirmed my intuition.) When you make that decision, sex is a “mindful” activity: You anticipate and plan it and prepare physically and emotionally for an optimal experience with your partner.

Many women grieve the loss of a part of their lives that was once so important and fulfilling. It’s most often an unnecessary loss, and staying sexually active has many health benefits as well as giving us feelings of both individual wholeness and connection to our partners.

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One of the motivations for my work with women both in my practice and through MiddlesexMD is the difference staying sexy makes for women in their relationships. I’ve heard anecdotes on both sides of the issue: from women who feel the intimacy with their partners drifting away, and from women who’ve reignited their sex lives and feel a burden lifted in their relationships as they and their partners re-engage.

So I was especially interested to see a study announced this month that puts some numbers to those observations. The study was led by Adena M. Galinsky and Linda J. Waite through the University of Chicago’s Center on Demography and Economics of Aging. I’m waiting the full text of the study, but an article in The Washington Post provides some interesting highlights.

A healthy sex life helps couples dealing with physical illness. Illnesses, especially chronic ones, can stress a marriage at any age. The study results showed that couples with more sexual intimacy viewed their marriages more positively in spite of illness.

msmd-features-368x368_bookAssessments of relationship quality are tied to frequency of sex. To put it plainly, couples who had sex more often were more likely to say they had a good relationship. In other studies, good marriages have been shown to prolong life—and certainly quality of life.

At any age, we can “expand [our] idea of what sex is,” according to Amelia Karraker, postdoctoral fellow at the Population Studies Center at the University of Michigan. I look forward to studying this part of the study in detail, because many of us grew up thinking sex equals vaginal intercourse. When that becomes uncomfortable or less pleasurable, too many of us think we’re done with sex.

This study’s data encourage us to keep sex as a part of our lives for just as long as we’d like to. When sex changes for us, we only need to learn about what’s different and how we can compensate (and engage our partners along the way). When we abandon that part of ourselves, we accept an unnecessary loss—to ourselves and our relationships.

“Wellbeing in older age incorporates both psychological and physical wellbeing as well as sexual wellbeing, which can occur at the intersection of those two,” Karraker said. Or, to put it another way: Sex is part of our physical and emotional health. Our whole lives.

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As a menopause care provider, I have lots of conversations with women about sex. I’ve heard confirmation that our motivations to have sex change with our situations. What motivates us when we’re young and single is very different from what motivates us when we’re older and in longstanding relationships, or older and single.

So when we suffer from lack of desire—are we missing the sort of drive we had when we were teenagers? Or is it possible we just haven’t found a new motivation for sex? The more we learn from women, the more it seems that for us sex doesn’t always begin with lust, but instead starts in our hearts and minds. We engage in our heads first, decide to have sex, and then with enough mental and emotional stimulation, our genitals respond. The older we grow, the more this is true. Age and maturity bring a new game into the bedroom.

MiddlesexMD_ChristieFor us, having sex is less an urge than a decision, one we can make and then act upon. When we decide to say yes instead of no, decide to schedule sex instead of waiting (perhaps for a very long time…) for our body to spontaneously light on fire, decide to engage with media or methods that will put us in the mood rather than wait for romantic moments to happen along, we’re using our heads to keep sex in our relationships.

Deciding to be intimate unlocks the pleasure. And the more sex we decide to have, the more sex we will feel like having. That’s the secret to regular bonding.

Why just decide to do it? This much we know:

  • Sex leads to a longer life.
  • Sex, like all exercise, helps protect us against heart attack and possibly stroke.
  • Hormones released during sex may decrease the risk of breast cancer and prostate cancer.
  • Sex bolsters the immune system.
  • Sex before bed helps us get to sleep.
  • Sex burns calories.
  • Sex can help relieve chronic pain, including migraines.
  • An active sex life is closely correlated with overall quality of life.
  • Good sex can protect us against depression, reduces stress, and increases self-esteem.
  • Sex with your partner stimulates feelings of affection, intimacy, and closeness.

That last point is what I hear most often in my practice: Women want to keep or already miss the intimacy with their partners that mutually satisfying sex communicates. While they also miss the feelings of power and wellbeing that sex gives them, it’s the loss of connection that impels them to take action.

And you can take action, too. We don’t need to wait around for “desire” to lead to thoroughly satisfying sex. We can use our heads.

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