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Archive for January, 2017

You say orgasms are new to you (congratulations!), and, having had the experience, you’re looking to  explore it further. You’re not sure your clitoris matches what you’ve read in books.

You asked. Dr. Barb answered.The external part of the clitoris is the head or glans; the shaft is deep to that. When you touch the clitoris, you’re touching the clitoral head. With arousal, there is usually minimal “engorgement” noted for women. By comparison, think of the penis, whose head doesn’t enlarge all that much when aroused. It’s the penis shaft that enlarges, and for women, the comparable clitoral shaft is internal (here’s a blog post with an illustration, which could be helpful).

A person’s size, weight, and number of pregnancies or childbirths don’t usually alter this part of our anatomy. As we age and hormone levels decrease, the clitoris does diminish in size and there can be skin conditions of the vulva that make the clitoris more “hooded.”

The most consistent, reliable way for most women to experience orgasm is direct clitoral stimulation (for others it’s vaginal at the “G spot”), and a vibrator tends to provide that for most women. But “most women” isn’t “every woman,” so there are a couple of other things you could try:

  1. A new clitoral pump, the Fiera Arouser for Her, may bring additional pleasure (and at a recently reduced price). It engorges the genitals during “before-play,” which usually brings more sensation and pleasure during intimacy.
  2. Warming products can be helpful in the same way, providing stimulation to bring more blood supply to the area.

I wish there were a single route to experiencing orgasm–or maybe I don’t. There’s something nice about it being individual and unpredictable. Continuing the pursuit is fulfilling and, I hope, ultimately satisfying, too!

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RESOLUTION #4

For this last of our January resolutions series, we’ll break from our discussion of underappreciated body parts but remain totally in keeping with MiddlesexMD’s tradition of confronting embarrassing issues head-on and unfiltered. Specifically, those we avoid talking about with our doctors.

Admit it, most of us don’t like to discuss topics having to do with sex, elimination, mental health, gender orientation, obesity. Often these topics are surrounded by social ambivalence or downright discrimination. We want to be healthy and normal. We don’t want to have problems, and we sure don’t want to air them with a semi-stranger.

Doctors have heard it all. That's our job.The doctor/patient relationship can be clumsy, strained, uncomfortable or superficial. Some providers are simply more skilled at coaxing out and straightforwardly addressing your intimate questions. If you find that your doctor is abrupt or unapproachable, or if you just don’t have good chemistry, you ought to—and have every right to—change doctors. Along with your dentist and auto mechanic, this is one individual you have to trust.

I want to assure you that doctors have heard it all. Not only that, we want—and need—to know what’s bothering you emotionally or physically. That’s our job, and we can’t do it effectively if you decide to soldier on. Often, that embarrassing secret can be easily treated; sometimes, it’s a symptom of something more serious that needs further testing.

Too often, however, patients wait until the “doorknob moment.” The exam is all wrapped up, and the doctor is literally almost out the door when the real question tumbles out: Oh, and I have noticed blood in my stool a few times recently; or, is it normal to have pain with sex?

If you don’t mention it, you doctor can’t address it. And if you wait until the doorknob moment, you may have to schedule a second visit so your provider can adequately assess the problem.

Here are examples of some of the questions that are either quirky or hard to bring up. Feel free to add your own in the comment section—or email me for a personal reply. While I can give you my best response, this in no way lets you off the hook from getting in-depth, personalized information from your own doctor.

  1. I’ve never had an orgasm. Is that weird? No. Female orgasm is a tricky business. Most women fake an orgasm at some point; about 5 percent of women never have one. But just because you’ve never had an orgasm doesn’t mean you never will. Here and here is some starter information. With some coaching, some understanding of your physiology (most women orgasm clitorally, not vaginally, for example), and some practice, chances are good that you’ll awaken those slumbering nerve endings.
  2. Do I look normal? “Normal” encompasses such broad and beautiful variety that there’s almost no such thing. Vaginas and labia, breasts and bellies come in a wide range of sizes, shapes, and colors. They aren’t often symmetric, and size and color can change with age and sexual activity.  Don’t believe me? Take a look at this art installation of real female genitalia.
  3. Why am I growing facial hair? This is another side-effect of normal, hormonal changes during menopause. Often, facial hair becomes thicker and coarser as well. You should mention this to your doctor just to monitor the changes and rule out other causes.
  4. Does it matter if I use drugs recreationally? Yes, it matters to your doctor. We need to know what’s going into your system, so we can correctly diagnose problems and be aware of possible interactions with other pharmaceuticals. This has nothing to do with law enforcement and everything to do with your healthcare—and sometimes even your life. We need to know about even benign recreational drug use, such as marijuana.
  5. Sometimes I leak and sometimes I smear. Female urinary incontinence is very common. The number of people who suffer from fecal incontinence, however, is harder to estimate because, surprise!, patients are too embarrassed to talk about it, and their doctors don’t ask. If either is problematic for you, ‘fess up. Talk about it. Treatment is available.
  6. I’m postmenopausal, and I’m bleeding. Definitely an issue to discuss with your doctor. Most postmenopausal bleeding is a result of thin, dry vaginal tissue, but more serious causes have to be ruled out.
  7. Why does my vagina make a strange sound during sex? Vaginal tissue is made of pockets and folds. (That’s how it expands to accommodate an 8-pound baby!) When air gets trapped in the pockets, penetration can push it out. The sound is called queefing, and it happens to lots of women.
  8. Am I ejaculating during sex? It’s possible. Female ejaculation is defined as fluid ejected from the urethra during climax. Colloquially, it’s called squirting. The phenomenon isn’t common but has been reported often enough that it isn’t a myth, either. Frankly, not much is known about why it happens or what the fluid is, exactly. Consider yourself special and stay tuned for more information.

Pick up your courage and a pencil and do yourself a favor: Write down all the questions, sexual, messy, and embarrassing as they may be, to ask at your next physical. You can also answer the questions in this quick and easy Menopause Map to begin framing the questions.

“In the end, we all just have to become comfortable with the fact that sex involves the genitals and the genitals are down there. It’s a big, messy thing—but it’s worth it!” says Dr. Debby Herbenick, in this article.

 

 

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I Will {Heart} My Heart

RESOLUTION #3

This is the tough one, ladies, but it’s also the most important. Cardiovascular disease (heart attack and stroke) is the #1 killer of women today. One in 3 women die from it. By comparison, 1 in 8 women die from breast cancer.

The news gets worse: about 44 million women in the US are affected by cardiovascular disease right now. Ninety percent of us have at least one risk factor, such as high blood pressure, diabetes, smoking, or being overweight. We are less likely than men to survive our first heart attack.

Fortunately, perfection isn't required.But the really good news is that 80 percent of cardiovascular problems can be prevented by knowledge and lifestyle change, according to the American Heart Association (AHA). The other bright spot is that improving heart health also improves our brain health, because good brain function relies on good cardiovascular function. And we know that as we age, we are at higher risk for various dementias.

It’s important to honestly tackle those lifestyle changes right now because as we age, our risk factors for heart disease increase: cholesterol and blood pressure tend to rise; we tend to gain weight; sleep may be more difficult. So time, very literally, is of the essence.

Unfortunately, lifestyle change of the type required for good cardiovascular health is hard. Honest, systemic lifestyle change demands consistency, and self-discipline, and this is hard. Few among us achieve perfection when it comes to an overall health care regimen.

Fortunately, perfection isn’t required. Getting started and sticking to it is.

To get started, assess your current baseline. These are the most important numbers:

  • Total cholesterol less than 200 mg/dL
  • HDL (good) cholesterol 50 mg/dL or higher
  • LDL (bad) cholesterol less than 100 mg/dL
  • Triglycerides 150 mg/dL
  • Blood pressure less than 120/80 mm Hg
  • Body Mass Index less than 25 kg/m2 (Find your BMI here.)
  • Waist circumference less than 35 inches

Second: discuss your numbers with your doctor to get your marching orders: hash out what to focus on; what is possible, and how best to begin, especially regarding an exercise regimen.

And third: Get started! Every one of those important numbers measuring cholesterol levels, blood pressure, blood sugar levels, and weight can be moderated or controlled through diet and exercise. That’s it. A clean, heart-healthy diet and regular moderate activity could extend your life and help you to avoid the serious consequences of heart disease. Plus, you’ll feel better, experience less pain, and be more flexible.

This is a once-in-a-lifetime deal.

A heart-healthy diet for a woman over 50 should rely heavily on fresh fruits and vegetables, lean meat and lots of fish, whole grains, and unsaturated fat, such as olive oil. Cut way back on salt, sugars of all sorts, saturated and trans-fats.

Cook your own food so you know what’s in it. Processed foods are full of sodium and unpronounceable additives. Make eating out a rare treat.

Both Weight Watchers and the Mediterranean diet get high marks from nutritionists as being heart-healthy, not too restrictive, and easy to follow—thus good candidates for a successful lifelong change.

Drink lots of water (we lose the tendency to feel thirsty as we age) and take your multi-vitamins and supplements, such as calcium and vitamin D, as advised by your doctor. Here’s a ton more diet information from the AHA’s Go Red for Women campaign.

Exercise is the second leg of cardiovascular good health. It’s hard to overestimate the benefits of regular, moderate activity—it regulates blood pressure, strengthens your heart and other muscles, increases bone density, and improves your mood.

The trick with exercise is to get started and to keep going because you will use every distraction in the book to procrastinate. It doesn’t have to be hard or expensive. A brisk, 30-minute walk 5 times a week—that’s all! Start with 10 minutes if you’ve been sedentary, but keep challenging yourself.

If you live in an area with cold winters, you can walk in the mall or do cardio workouts at home with some of the very good fitness videos available online. Here’s a beginner workout from the inimitable Jane Fonda, who imparts salty health advice along with encouragement. Here’s a no-nonsense and very comprehensive set of workout programs to explore once you’ve built up some stamina. Stick with low-impact workouts, warm up thoroughly, and don’t overdo. Steady, consistent progress is better—and safer—than a jackrabbit start.

Finally, stop smoking. Not negotiable. Smoking adds incredible risk to your health. Do whatever it takes to eliminate nicotine from your life.

It’s January. This is a good time to seriously take charge of your health. Imagine how incredible you’ll feel after spending the entire year working out and eating clean. Imagine actually witnessing the change in those numbers. Buckle up for a life-changing year.

 

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You asked. Dr. Barb answered.You say you’re hoping to enjoy intercourse again after a five-year hiatus, but that you experienced some discomfort with your last gynecological exam. The prescriptions offered to you (which I assume were localized estrogen) are not in your budget, so you’re wondering about other options.

A vaginal moisturizer, used regularly, can help you regain some tissue elasticity. Any of the moisturizers we offer might be an option for you; they’re intended to be used regularly, from daily to several times a week.

Along with thinner and fragile tissues, in menopause, without estrogen and without sexual activity, the vagina will become more narrow and shortened. You may need the gentle stretching of dilators to help restore vaginal capacity.

I’m hopeful that, with some effort and regular attention, you can restore vaginal health to resume pleasurable intercourse!

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I Will Improve My Pelvic Floor

New Year Resolution #1

Resolutions are easy to make and hard to keep (most people don’t). However, as we mentioned before, certain psychological tricks can increase your chances for success, and sheer persistence is one of them.

In the spirit of successful resolutions, I propose devoting January (yes, the whole month) to specific health-related resolutions. In fact, each one focuses on an often neglected body part that is critical to good sex and/or well-being.

First up? The pelvic floor.

You might not think much about your pelvic floor, but it affects you every single day. That surprising leakage after your firstborn child? That need to pee every half hour now that you’re post-menopausal? The more frequent UTIs? The slack “vaginal embrace” during sex? That really annoying pelvic organ prolapse that’s causing all manner of issues?

Strengthen your floorAll these annoyances (and more) are related to the muscles in your pelvic floor. That’s why we write about pelvic floor health and doing kegels so much on MiddlesexMD. That’s why a healthy pelvic floor is part of our recipe. That’s why we have products to help you do those kegels right.  It’s all because a healthy pelvic floor is so darned critical to our quality of life, especially as we get older and lose muscle tone and elasticity.

While many lifestyle improvements—losing weight, not smoking—will coincidentally improve the pelvic floor, they aren’t the stuff of resolutions that are easy to keep. Kegels, on the other hand, are specific, countable, time-limited, and realistic—all the elements of a solid, successful program.

And now, they can be fun! (Another element of success.)

A new smartphone app combined with a high-tech vaginal tool was recently launched on the crowdfunding website Indiegogo. Perifit is an exercise tracker/trainer for your pelvic floor. It’s comprised of a flexible, bulbous, silicone tool that goes in your vagina and sends low-energy Bluetooth signals to an app that is downloaded onto your smartphone, tablet, or laptop.

For resolution success, make it specific.If you’re successfully tightening your pelvic floor, a butterfly stays afloat on your device. The tighter you squeeze, the higher it flies. Not only will you know if you’re tightening correctly, but the tool also measures both deep and shallow muscles contractions as well as their effectiveness against four parameters: force, endurance, reflex, and agility. You also get to choose among several training programs targeted toward specific issues, such as different types of incontinence or post-childbirth trauma.

The program isn’t cheap, and it’s also new, but it’s a hugely fun concept and casts the notion of doing kegels in a refreshingly different light. If nothing else, watch the video with the adorable baby and draw comfort from the fact that women of all ages are working on their pelvic floor.

Like any workout, developing pelvic floor muscle takes time and consistency. Whether your success with this program depends on a butterfly video or vaginal weights or your own self-discipline, you have choices among several tools, one of which might align well with your personality.

The last element to a successful resolution is persistence. Of course you’ll forget or skip days or get lazy. The secret is to pick up where you left off and keep on going. Set up a realistic, measurable program. Healthline recommends holding a kegel for a 3 seconds; releasing for 3 seconds and working up to a 10-second hold.  Three sets of 10 ten-second reps a day is a good goal.

Developing pelvic floor strength isn’t as obvious or satisfying as working on tanktop arms or a bikini belly (if that’s even possible anymore), but it is arguably more important. Avoiding or reducing incontinence, UTIs, and pelvic organ prolapse while increasing sensation and vaginal strength for better sex is nothing to sneeze at.

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I’m afraid this is a complicated issue. A dozen different contributing factors are possible, and the challenge you and your wife face may be a combination of them. You’re not alone, which is, I recognize, both bad news and good news.

I’ve addressed low libido and many of the contributing factors in blog posts before. Here’s the introduction to the topic on our website; here’s a blog post with additional explanation. Here is a list of answers to specific questions readers have submitted, including certain health conditions or medications which can inhibit libido as a side effect.

You asked. Dr. Barb answered.You didn’t describe your wife’s overall health; I hope she’s had a recent evaluation from her health care provider and has mentioned her loss of interest in intimacy. He or she can help to determine the cause, which will then point to the best options for treatment. You may also find a couples therapist or a sex therapist to be helpful, since emotional as well as physical factors come into play in intimacy.

I do wish you the best with finding the cause and some ways to address it! Physical intimacy adds meaningful dimensions to our relationships.

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