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Archive for February, 2017

You say you’ve had a period and some breast tenderness after three years of hormone therapy (HT). I hope you’ll make an appointment with your health care provider: Any bleeding that occurs postmenopausally (after 12 months with no bleeding) is considered “abnormal uterine bleeding” and it really deserves evaluation. This is true whether or not you’re on HT.

The evaluation is usually an endometrial biopsy, a quite simple office procedure. Women on hormone therapy are at very low risk of developing uterine cancer, but we still want to make sure the proper evaluation takes place. Usually the biopsy is completely benign or normal, and we aren’t able to explain why it happened.

You asked. Dr. Barb answered.When the bleeding is accompanied by other associated symptoms, like breast soreness, it is tempting to attribute it to a “last hurrah” or one last period, but that is unlikely. Any missed doses of the HT or changes in dosing can occasionally contribute to some breakthrough bleeding. The most likely scenario is that the hormone therapy contributed to the symptoms of the breast soreness and the bleeding, but without any changes it’s hard to explain why that might have happened now, three years after menopause.

Again, evaluation usually confirms that all is normal, but it’s worth making the effort to be sure!

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Not much is known about addiction to pornography, not the numbers of people affected; even the definition is hazy. There just isn’t a body of research surrounding the issue.

“There is a real dearth of good, evidence-based therapeutic literature,” says Dr. Valerie Voon, a neuropsychiatrist at the University of Cambridge in this article.

The relatively recent advent of the Internet has revolutionized the world of porn, serving up  raw, unfiltered, hard-core, and nonstop stimulation. The result is a cohort of (mostly) men who have become addicted and desensitized to the dopamine rush of a constant barrage of online porn. Occasional porn consumption is common, but therapists and doctors are seeing more relationship and sexual performance difficulties among heavy porn users—behavior that looks a lot like addiction.

Discovering that your partner uses porn addictively is a crushing, confusing experience. Women compare it to the betrayal of discovering an affair, except that the “other woman” is a computer screen that is available 24/7 and that doesn’t look or act like a normal woman.

A partner’s initial response is often denial: Is it really so bad? Doesn’t everyone view porn sometimes? Is this normal?

The morality or “normalcy” of porn use is a different conversation, but when a partner becomes secretive and withdrawn, when he can’t stop the behavior even at work or, as one woman discovered, during a weekend visit to her parents; when porn use creates difficulty in real-life sexual performance; when it causes pain and conflict, then it’s an addiction and it isn’t normal.

Porn addiction is socially anathema—people don’t talk about it or easily admit to having a problem with it. Support groups for partners of porn addicts are rare. And research-driven treatment for porn users themselves is also rare. The most common treatment is called a “reboot” in which porn users are counseled to stop masturbating to online porn until their brain chemistry and ability to engage in real-life sex is regained, which may take months.

The behavior of porn addicts is similar to other addictions. They minimize their porn consumption or outright lie about it. They may accuse the partner of causing the problem. They withdraw and hide what they’re doing. They may gaslight—a newly vogue term that refers to undermining the partner’s grasp on reality by lying, evading, bullying, and blaming.

This dynamic is devastating and toxic. Partners of porn addicts are often recognized as having symptoms of PTSD-like trauma.

The non-porn-using partner may try to control “the addict’s access to porn through anger, snooping, crying, guilt tactics, threatening, shaming and blaming the addict. This destructive behavior was once considered co-dependent, but those of us who work with partners of porn addicts now view these actions as symptoms of trauma,” writes Mari A Lee, sex addiction therapist and co-author of Facing Heartbreak: Steps to Recovery for Partners of Sex Addicts.

As with any addiction, the path to recovery is difficult and riddled with relapse. The harrowing challenge to a partner of a porn addict is to maintain her own integrity and emotional health while offering her partner forgiveness and the space and support to manage his recovery, if he so chooses.

Women who’ve been there say:

  • This isn’t about you. Your partner’s behavior has nothing to do with how you look, how much you weigh, or your performance in bed. Don’t take the blame. “[P]orn addiction is not about [the non-addicted partner’s] worth or value, it is not even about sex; instead, porn addiction is about soothing pain,” writes Lee.
  • “You did not cause it. You cannot change it, and you cannot control it.”
  • Try not to let your partner’s addiction take over your life or consume your thoughts. Set goals. Stay active. Stay healthy.
  • Try to find support—a therapist, a group, a trusted friend.
  • Respond to your partner with as much compassion and forgiveness as you can muster without becoming sucked into the addiction.

A partner’s addiction may be one of the most painful and difficult knuckle sandwiches that life can smack you with. It attacks the very foundation of trust, security, and intimacy that a relationship is built on.

However, there is hope, both for your own healing and the recovery of your partner. “When each person makes the choice to end the destructive dance of addiction, blame, shame and hurt, and instead chooses to move toward healing and recovery – miracles can happen and relationships can heal,” writes Lee.

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A patient came to see me a few days ago. She had been in a sexless marriage for years—and she had recently discovered at least part of the reason. Her husband was addicted to pornography.

This is more common than you think. It’s also not a simple problem.

Lots of people—men and women—consume porn at least occasionally. Estimates range from 50 to 99 percent of men and 30 to 86 percent of women—numbers that are so broad and vague as to only suggest “a lot.” Women tend to watch porn with their partner and to consume softer types—erotica might be a better term. Women usually report feeling greater intimacy with their partner after viewing porn.

Men tend to consume porn alone, and it portrays sometimes aggressive and sometimes deviant forms of sex. A heavy diet of this can cause them to withdraw from intimacy and to feel “increased secrecy, less intimacy and also more depression,” says Dr. Ana Bridges, a psychologist at the University of Arkansas in this article.

Porn has been around since time immemorial. What’s changed is the amount and type of porn that’s available online all the time. We aren’t talking about the Playboy or Hustler magazines from a previous generation. This is hard-core, porn-on-steroids content served up in any flavor to satisfy the wildest imagination. These aren’t normal bodies, it’s not real sex, and it’s available any time, day or night.

Although the scientific community has been hesitant to label such consumption as an addiction, and although many people, perhaps most, view porn occasionally without guilt or moral quandary, plenty of anecdotal evidence suggests that a problem is brewing.

Whatever you call it—addiction or compulsion—when an activity becomes uncontrollable and consumes many hours; when it affects performance at work, compromises intimate relationships, and physical or emotional health, then it’s a problem.

Therapists and doctors are increasingly seeing patients who report less interest in sex and sometimes an inability to have sex in real life. Erectile dysfunction is showing up in greater numbers, especially in young men who began viewing porn while still in their teens.

Or, like me, healthcare practitioners are hearing from confused, distraught partners who don’t understand what’s happening to their partner and to their relationship.

The mechanism that creates the problem is only beginning to be studied and understood. Consuming porn many times a week over a period of months (or years) is a solitary, alienating, guilt-inducing pastime.  It frequently changes the way a person interacts sexually with a partner in real life—the person is often more impersonal, distant, and sometimes rough or demanding. Sometimes the person withdraws from the partner altogether.

Heavy porn viewing actually changes brain chemistry. In a small but carefully conducted study, a group of German researchers determined that high levels of porn consumption results in a shrinkage of gray matter in a specific region of the brain. Researchers were unsure whether this reduction was caused by the “wearing and downregulation of the underlying brain structure” due to hours of porn consumption or whether the subjects consumed porn because they had less gray matter in this area to begin with and needed more stimulation to experience pleasure.

Generally, however, the hypothesis is that heavy porn consumption desensitizes the viewer, so that more intense levels of consumption are required to reach the same level of satisfaction. “You need more and more stimulation as you build up this tolerance, and then comes your reality with a wife or partner, and you may not be able to perform,” said Dr. David Samadi, chairman of urology at Lenox Hill Hospital in this article. “It’s a problem in the brain, not the penis.” As such, drugs for erectile dysfunction, such as Viagra, aren’t effective. The penis may engorge, but orgasm doesn’t follow.

Obviously, ongoing porn consumption is problematic for a relationship. It can persist for years, with trust and sexual intimacy almost inevitably becoming collateral damage. The situation is confusing, hurtful, and debilitating to a partner, in part because the issue is so socially unsavory and so rarely discussed.

I’m thinking it’s time to crack open the door and begin talking about porn addiction, how to recognize it, and what a partner can do about it.

 

 

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Sexual partnerships are as variable as snowflakes. Each couple dances to a unique harmony. For some, sex remains a vibrant and fundamental part of the love and intimacy between them. But for many others, sex fades into a boring and infrequent routine or it just doesn’t happen at all. And that’s not a happy place to be.

Each couple dances to a unique harmony.For many couples, sex—or the lack of it—becomes the white elephant in the room. They ignore; they avoid; they work around it. But generally, it’s an underlying irritation and cause of increasing anger, frustration, and dissatisfaction. Whether lack of sex is the cause of these emotions or is collateral damage caused by other problems becomes hard to tease out. Just the fact that the darned elephant is sitting there on the couch takes a lot of energy to ignore.

Relationships without sex are common—it’s estimated that from 20 to 30 percent of marriages are sexless, which is roughly defined as having sex 10 times per year or less. Even though women tend to struggle more with libido during menopause, “women don’t have a corner on low libido,” says Michele Weiner-Davis, therapist and author of The Sex-Starved Marriage in this very worthwhile Ted talk.

The number of times couples “do it” per year isn’t the point. Really, who’s counting? It’s the level of contentment and connection between them that counts.

“If a couple is OK with their pattern, whether it’s infrequent or not at all, there isn’t a problem,” says clinical sexologist Judith Steinhart in this article. “It’s not a lack of sex that’s the issue, it’s a discordant level of desire.”

And that discordant level of desire—when one partner wants sex and the other doesn’t–can cause deep, relationship-destroying pain.

We’re hard-wired for connection. We crave intimacy and emotional safety within our committed relationships. And sex is a powerful intimacy-builder.

But when it becomes the sole task of one partner to ask for sex, and when he or she is frequently rejected, a hurtful dynamic is set in motion. More is at stake than a roll in the hay. One’s self-worth and sense of being attractive to, connected to, and cared for by a lover is on the line. In research studies, that kind of rejection activates the same parts of the brain as physical pain.

Over time, repeated rejection morphs into anger, frustration, and contempt—or withdraws into boredom. Communication and connection on other levels shut down. Intimacy flattens like stale beer. We all know couples who don’t touch or make eye contact, or share a joke.

With discordant levels of desire, the person with less need for intimacy controls the relationship, says Weiner-Davis in this article. The bargain goes like this: “I am not into sex. You are. But I don’t have to care about your sexual needs. Furthermore, I expect you to be monogamous.”

Besides being unfair, the fatal flaw of this unspoken agreement is that relationships are built on mutual caretaking, and when that falters, the essential contract begins to crumble. Sex in a loving relationship is a reaffirmation of that mutual caring—a giving and receiving of pleasure, intimacy, and trust. That’s what we all deeply long for, and if it goes away, we deeply grieve its loss.

So, whether you’re the withholder or the seeker in your relationship, there’s good news. Even couples in long-term relationships can reignite the flame. “It’s never too late to have a passion-filled marriage,” say Weiner-Davis. That doesn’t necessarily mean shades of gray, sex on the kitchen table kind of passion, but it does mean a renaissance of sexy touch, playfulness, cuddling, and general “canoodling,” says Foley.

For starters:

  • Explain how you feel. Often, the partner with a lower libido doesn’t understand the hurt caused by rejection and lack of physical intimacy. Explain how much you miss the physical expression of love in your relationship. That it’s painful to feel he or she isn’t interested in being close to you. That you don’t want to settle for parallel, unconnected lives. That sex is important.
  • Just do it. If you’re the low-libido partner, sometimes, you just have to get started in order to feel desire. If your partner clearly needs a little cuddle time, seize the opportunity to please and affirm your partner, whether you feel like it or not. If you can’t get into the mood, you can touch, kiss, and pleasure your partner in other ways—masturbation or oral sex, for example.
  • Get creative. Familiarity and routine can be a serious buzz kill in a long-term relationship. Sometimes, mixing it up a little reignites the spark. Maybe recall the moves that used to turn you on or maybe take a midwinter break for a rejuvenation weekend. Be new lovers for each other.
  • Get a physical. We all slow down with age. This isn’t problematic in itself, but if the slowing is one-sided or if either or both of you want more action between the sheets, then a complete physical workup should be one of your first steps—for men and women. Sexual functioning is linked to so many physical and emotional variables—medication, stress, depression, illness—that teasing out the possible intersections is a job for the professionals. Once they’re diagnosed, sexual issues can usually be treated or improved.
  • Get counseling. Maybe you need a few sessions to jump-start communication. Maybe you need a deeper dive to unearth ingrained bad habits. Counseling, group therapy, a marriage retreat or some other reset might help address blind spots and self-defeating behavior. If your partner doesn’t want to go, you should go alone. “Counseling can help you figure out strategies to help yourself,” says Sallie Foley, director of the Center for Sexual Health at the University of Michigan in this article.

Tackling a sexless marriage isn’t easy. Even if the status quo is unsatisfactory, changing it is risky and uncomfortable. If you’re continually gnawing on irritation; if you feel rejected and unattractive to your partner; if you’ve shut down and settled for boredom, it’s time to rattle that cage, express your feelings in a loving way, and actively seek out help.

 

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