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Archive for December, 2014

As we mentioned last time, 47 percent of New Year’s resolutions are related to self-improvement—losing weight, quitting smoking, getting organized, or saving money. “Improving sexual health and wellbeing” doesn’t make the list (at least not the one in this study) but we think they should.

Because—let’s face it—chances are, they won’t magically get better on their own.

They used to, though, didn’t they? Or it seemed like it. Over the course of our relationships, all of us have probably experienced sexual desire come and go, as we went through things like pregnancy, health-related issues (for us or our partners), and times of stress. Looking back, we remember that desire always bounced back, as it does for most people who are generally healthy and on the young side of middle aged.

But at this stage of the game, how long should you let it go, hoping it will self-correct, before resolving to do something about it? Our take: Not long. Start now. You’ve got nothing to lose and so much to gain in the area of self-improvement.

Although we may not think of intimacy and sex falling into the “self improvement” category, it actually does. Do you want to lose weight? Be healthier? Feel better about yourself? Then get busy, sister, because having sex can help in all those ways. Equally as important is that when sex is good, as you’ll recall, it adds 15 – 20 percent additional value to a relationship; when it’s bad or nonexistent, it drains the relationship of positive value by 50 to 70 percent.

Make 2015 the year that you make a concerted effort at doing what it takes—kegels for better muscle tone, a vaginal moisturizer as part of your skin-care routine, lubricants or a vibrator to add some spice, an honest conversation about foreplay with your partner—to get your game on in the bedroom. Don’t just say you will; make it your New Year’s resolution. Research shows that if you make a resolution, you’re 10 times more likely to have been “continuously successful” at six months than if you don’t. Good luck and Happy New Year!

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We know and have mentioned before that relationships and connection are what make us happy. And yet when it’s time to make a New Year’s Resolution, what do we choose? According to one study, 47 percent of us make self-improvement related resolutions, 38 percent make weight-related resolutions, and 34 percent make money-related resolutions. Only 31 percent of us make relationship-related resolutions. (Respondents could choose more than one answer.) The question didn’t break out romantic from non-romantic relationships, but it’s still fascinating that the response came in last on the list.

I don’t know why we are less likely to make resolutions about improving relationships. Maybe we think our relationships, especially with our significant others, are so deeply grooved that rejuvenation is unlikely. Maybe we underestimate our partners’ willingness to entertain the idea of change. Maybe the idea simply doesn’t occur to us.

Whatever the reason, we’re missing an excellent opportunity. I’d like to challenge you to make a New Year’s resolution to improve your relationship with your partner. It could be as simple as “I will make eye contact when we see each other at the end of the day” or “I will tell my partner one thing I appreciate about him/her every day.” Even simple things increase intimacy, which is the basis for a healthy sexual relationship.

If you have already mastered intimacy, then perhaps make a resolution to try something new in the bedroom—a new position, a new technique, or a new toy. Perhaps you and your partner could decide together what kind of resolution to make. That will increase the comfort level when you actually hit the sheets. On the other hand, don’t underestimate the power of small surprises to reignite passion. As we mentioned in a previous post on the love/desire paradox, we want security and passion, intimacy and mystery, safety and risk. So push that boundary a little and see what happens.

You can increase your chances of keeping your resolution if you:

Be specific. “I will try a new sexual position every month” vs. “I will try new things in the bedroom.”

Tell someone. Preferably your partner! But it could also be a close friend. When others know you have goals, you’re likely to hold yourself more accountable.

Write it down. There’s something about committing it to paper that makes it seem official. And it will help you remember exactly what you committed to!

There are other ways to increase your odds of making your resolutions reality, which is a good thing since only 14 percent of people over 50 keep their resolutions compared to 39 percent of people in their twenties, according to research. Apparently, those of us over 50 need as much help as we can get!

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I recently read a book review recounting one woman’s harrowing passage through perimenopause. The Madwoman in the Volvo is a graphic and humorous account of emotional upheaval, distress, seismic life changes, and finally, the author is cast gently upon the slightly less fraught shores of menopause. Perhaps sadder (or more thoughtful), probably wiser, and definitely optimistic about the future.

So, in honor of this season, which is guaranteed to nudge all but the most stoic among us off the ledge, I have two messages for all of us hot-flashing, sleep-deprived, hormonal gals.

If you feel as though you’re losing your mind, you aren’t alone. Hear that? You are not alone. In fact, you are legion—there are many of us.

Google “crazy menopausal women.” Read the forums. Check out the Fourteen Best Menopause Health Blogs of the Year. Take heart. You’re in abundant, albeit somewhat unhinged, company.

There are, in fact, a silent (or, more likely, howling) army of women who feel just like you. I recall the patient who was referred to me by her new therapist, who had refused to treat her until she got her hormones straightened out. (Previously, she had been told to see a therapist by the police.)

I recall a close friend, the very picture of motherly benevolence, who hissed in my ear, “If that kid doesn’t stop yammering at me, I’m going to tape her mouth shut.” She was referring to her sweet but talkative adolescent daughter. I was shocked. A few years later, I was feeling like that myself.

You can assess your lifestyle and experiment with healthy change. You can eat kale and take vitamin B12 and black cohosh. You can meditate and do yoga. You can stop smoking and reduce your alcohol and caffeine intake. You will feel healthier, and your symptoms might become more tolerable. In case you haven’t noticed, I’m a big advocate of healthy lifestyle choices.

But, if you, like many other women, continue to feel like you’re hanging on to sanity with bloodied fingernails, and those you love are suffering right along with you, by all means see your doctor and find out what pharmaceutical options might help you.

Read this article, written by a woman with access to all the current research on hormone replacement therapy (HRT) and an enviable journalistic pedigree. Here’s what she has to say about her decision to go back on HRT:

I would like to be able to tell you that I weighed these matters thoughtfully, comparing my risks and benefits and bearing in mind the daunting influence of a drug industry that stands to profit handsomely from the medicalizing of normal female aging. But that would be nonsense, of course. I was too crazy. I went straight to the pharmacy and took everything they gave me.

Perimenopause—the hormonal roller-coaster years preceding menopause—can be a long and bumpy ride. It usually begins somewhere between 45 and 55, but can start much earlier. These are the years of unpredictably cresting and crashing hormones, when the crazies come out in all their glory. This stage can last from 2 to 10 years.

Menopause officially beings in the thirteenth month (one year) after your last period.

Which doesn’t mean you’re out of the woods. Many women still have hot flashes and emotional turbulence. But life should slowly settle down as your body adjusts to its new, post-hormonal self.

So, that’s my second holiday message: You aren’t crazy, and eventually you’ll be okay. Wiser, maybe more self-actualized, and really, really okay.

With that, a very happy holiday from MiddlesexMD to you. And as the Madwoman in the Volvo said, “Have some cake, for God’s sake.”

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Low-fat mocha or chai tea latte? Caramel-cashew delight or plain vanilla?

Everyone likes choices. As a physician, I really like to have options in my toolkit. If one drug doesn’t work or causes unpleasant side effects, it’s nice to be able to offer my patients something else.

Recently, the FDA approved two new drugs for treatment of menopausal symptoms. Of course, they come with caveats, including questions on how truly effective they are, but I love having relatively safe options for my patients with unpleasant and sometimes difficult menopausal symptoms.

The ironic part is that both drugs are old friends in new packaging—one combines estrogen with a new non-hormonal compound; the other is an antidepressant that happens to be good at alleviating hot flashes.

The first, Duavee, was developed by Wyeth, a subsidiary of Pfizer, and came on the market last year. This drug takes a different approach to the traditional estrogen/progestin combo for women who still have their uterus. The estrogen part, Premarin in this case (called “conjugated estrogen”), eases the menopausal unpleasantness, while the progestin protects endometrial hyperplasia—the overgrowth of endometrial cells. (That’s why women who have undergone a hysterectomy can take estrogen-only drugs—they no longer have a uterus.)

Duavee replaces the progestin with bazedoxifene, a nonhormonal drug with the cumbersome classification of a selective estrogen receptor modulator or SERM. A SERM acts like estrogen in some tissues and it acts just the opposite in others, so bazedoxifene is also called an estrogen agonist/antagonist. It “selects” a tissue to either promote estrogen effects or block estrogen effects.

Yeah. Confusing. I know.

Here’s how Dr. Seibel, a well-known specialist in menopause and reproductive health, puts it, “The excitement about this medication is that bazedoxifene acts like a progestin, meaning it blocks the potential negative side effects of the Premarin [the estrogen component], but lets the Premarin continue to do its good stuff.”

The bazedoxifene component in Duavee does some other good stuff as well: It also protects against postmenopausal bone loss and “significantly increases bone mineral density,” according to Pharmacy Times.

So, according to the FDA, it can be prescribed for prevention of osteoporosis for at-risk women after other options without estrogen have been considered.

There are still risks to taking hormones, and the FDA still advises that, like any estrogen compound, Duavee be used at a low dosage for the shortest possible time for relief of menopausal symptoms.

For women who want to get away from hormones altogether, now there’s Brisdelle. Developed by Noven Therapeutics, Brisdelle is another old friend in new dress-up clothes—paroxetine, better known as Paxil. The “new” part is the very low dose.

Gynecologists have been aware for a while now that antidepressants can be helpful in relieving menopausal hot flashes, night sweats, and the sleeplessness associated with them. So sometimes we’ve prescribed antidepressants off-label.

The problem with that approach has been that the dosage for depression is higher than the dosage required for relief of menopausal symptoms (10 mg. rather than 7.5 mg.). The side-effects of that higher dosage can be weight gain and, god forbid, loss of libido. “The last thing a menopausal women needs is a drug that might sabotage her diet or an already waning sex drive,” says Dr. Streicher in this article.

Amen to that, sister.

With a dedicated drug like Brisdelle, you not only get the correct dosage to douse the flames of hot flashes, but you also avoid the confusion of being diagnosed with a completely different condition. A generic prescription for paroxetine would still be cheaper, but Brisdelle provides the right dosage for the right problem (hot flashes, not depression).

No drugs are perfect, but these two “new” drugs at least have a track record. They’re relatively safe and effective, and they add a couple of good options to the arsenal.

Nothing wrong with more choices, after all.

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In October, I traveled to Washington DC to participate in a public meeting and scientific workshop on female sexual dysfunction. The meetings came about because questions had been raised about whether the FDA was paying enough attention to women’s sexual health, and whether they’d set the bar higher for products for women than for comparable products for men (think Viagra or the 25 other prescription drugs for erectile dysfunction [ED]). ABC’s 20/20 found the meetings newsworthy enough to do a segment on the pursuit of “pink Viagra.”

I’m a pragmatic, Midwestern menopause care provider. I see women who are at all points of the spectrum from mild discomfort to despair. I make recommendations and write prescriptions for quite a range of options—from use of lubricants and vibrators to off-label testosterone. I certainly know that there’s no one-size-fits-all solution, no silver bullet, no magic pill that’s going to make every woman’s sexual experience legendary—or even comfortable.

As we’ve said before, women’s sexual desire, arousal, and response are complicated. Emotional security and intimacy, sexual history, and relationship satisfaction can make an already-complex reality even more difficult to untangle. Every woman deserves an individual approach. Every woman deserves a health care provider who can capably represent the options for treatment, when that’s needed—including describing the benefits and drawbacks. Every woman deserves to make her own choices to govern her quality of life—including her sex life.

So I watch with interest the discussion that’s transpired since the October meetings, reinforcing the messages I heard there. Sexual dysfunction is as real for women as for men. Yes, it’s true that some women find relief without pharmaceuticals. Yes, it’s true that there’s a profit motive for pharmaceutical companies. Yes, there’s a hazard in “medicalizing” women’s sexuality; we are not only biological systems. Yes, it often seems “pharma” is marketing out of control; I know I’ve seen enough ED commercials to last me the rest of my life.

And yet—if the FDA is charged with looking out for all of us, why wouldn’t that include women? And if they’re concerned with all health conditions, why wouldn’t that include sexual health? And if a pharmaceutical option is developed, and found by fair and rational standards to be both effective and healthful, why shouldn’t that option be made available to women who might choose to take advantage of it?

The FDA is accepting comments from the public—especially seeking insight from women who’ve suffered from sexual dysfunction—until December 29. You can read the questions in the FDA’s document online, and then submit your comments by clicking on the blue button at the right on this page on Regulations.gov.

Your story can help make clear what #WomenDeserve.

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Single? Sexual? Be safe

Recently, a friend and her sister visited a retirement community in our neighborhood. They chatted up several residents, including the sweet, 90-year-old widower who’d lost his beloved wife some months before. When they turned to leave, he asked the sister for her phone number. Since she is 50 and married, they laughed it off. Not long after, they heard that their elderly Don Juan had found himself a girlfriend in a nearby senior living community and was visiting her regularly.

The anecdote is cute, but it also points to a larger reality. We are never too old to enjoy sex—that’s the entire premise of this website—but somewhere on the road to the golden years, single seniors have thrown youthful caution to the winds when it comes to safe sex. The result is that sexually transmitted infections (STIs), such as Chlamydia and syphilis, are spreading more quickly among people over 55 than among any other age group except 20-24 year olds, according to a 2010 report from the Center for Disease Control and Prevention (CDC).

Even more alarming—one in four people with HIV/AIDS is over 50. In the Sunbelt, where large communities of seniors live, the rates of increase are off the charts: In two counties in Arizona cases of syphilis and Chlamydia among those over 55 rose 87 percent between 2005 and 2009; in central Florida, the increase was 71 percent, according to this article in Psychology Today. News reports use words like “epidemic” and “skyrocketing” to describe these increases. Medicare has begun offering free testing for STIs, but most (95 percent) of seniors remain unscreened.

What the heck is going on here? What happened to all those lectures in responsibility and self-control we subjected our kids to? What seems to be happening is that we are, luckily, more long-lived and healthier than our forebears. We are also newly empowered with drugs to maintain erections for men and to make sex more comfortable and enjoyable for women. All the years of hard work, career-building, and childrearing are in the rearview mirror. Many of us find ourselves alone and treading tentatively back into this brave, new world of sex and dating. Add to this the sometimes freewheeling life in retirement communities (some of which are the size of small cities), which create hotbeds (no pun intended) of people of similar age and background—kind of like a college dorm.

Trouble is, unlike kids in a dorm, seniors don’t have to worry about pregnancy and aren’t nearly as well-informed about the risks of unprotected sex. Condom use for those over 60 is the lowest for any age group (6 percent vs. 40 percent for college-age males). And condoms, in case you’ve forgotten, provide the only dependable protection against STIs, and even they aren’t effective against every sexually transmitted bug.

Also unlike their much younger counterparts, older folks have a less robust immune system, so the chances of catching and spreading infections are higher. Plus, many STIs are asymptomatic, so the person doesn’t know he or she is infected—and that the STI is degrading the immune system even further. Finally, doctors rarely think to ask Grandpa about his sex life in the normal course of an exam, even if he has classic symptoms of an STI.

All this adds up to a lively Petri dish of bugs circulating around the singles scene. Yet, prevention is so easy, and the cost of ignorance or of ignoring common-sense precautions is high. So, ladies, even if the prospective partner is someone you’ve known all your life, don’t assume you’re familiar with the intimate details of his sexual forays. Others have walked this path before—and are paying the price. Jane Fowler, 71, and founder of HIV Wisdom for Older Women, was infected with HIV by just such a friend when she was 55 and now advocates for more information and support for older women with AIDS. I’d suggest that if you’re dating, stick a couple condoms in your purse right with the lipstick. And get yourself tested if you’ve ever had unprotected sex. And read this series of posts about STIs on MiddlesexMD. The rule of thumb these days—better safe than sorry.

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