We blather on regularly at MiddlesexMD about the importance of good health—staying active, eating well, exercising, maintaining a healthy body weight. Given the many exercise fads that come and go (remember Jazzercize?), maybe it’s time to get specific about ways a mature woman can stay in shape.
Yoga is one of the best. Hardly a fad, yoga’s been around for at least 5,000 years; the earliest mention is in sacred Ayervedic texts in northern India. In the US, it’s now a $10 billion-a-year industry with 20 million practitioners.
As you can imagine, many styles of yoga have developed over the millennia, but the main forms you might encounter are:
What all these flavors have in common is a focus on the breath as a meditation and on moving at various speeds through a series of poses, which are sometimes very challenging. As such, it combines the calming effect of meditation with bodyweight strength-training of held poses.
The benefits of a regular yoga practice are impressive. Yoga clearly increases flexibility and strength, and improves balance. According to a slew of studies, the mind-body effect of yoga may also relieve stress and depression, lower blood pressure and heart rate, stabilize blood sugar levels, relieve chronic neck and back pain, and even improve brain function.
Referring to a 2015 study published in The European Review of Preventive Cardiology, an article in the Harvard Heart Letter reports, “over all, people who took yoga classes saw improvements in a number of factors that affect heart disease risk. They lost an average of five pounds, shaved five points off their blood pressure, and lowered their levels of harmful LDL cholesterol by 12 points.”
Despite the fact that some of these studies are small and not terribly rigorous, the consistent result is that, while yoga isn’t a cure-all, it helps to relieve some surprising conditions.
One of those small studies published in the Journal of Sexual Medicine reported that yoga can even improve sexual function. In this study, 40 women practiced yoga for an hour every day for 12 weeks. At the end of the study, 75 percent of them reported improvement in sexual satisfaction on several assessment areas, such as lubrication, desire, arousal, and pain. Women over 45 showed the most significant improvement in lubrication, arousal, and pain.
The good thing about yoga is that you can jump in and feel challenged at any fitness level, from couch potato to workout devotee. It’s low-impact, so it’s easy on the joints. It isn’t competitive, so you shouldn’t be looking over your shoulder (or between your legs) at the next person. It doesn’t require any equipment other than a mat, so don’t stress the gym wardrobe.
You can find yoga workouts online or on DVDs, but classes are offered everywhere as well. The glut of choice actually makes teasing out the best choice for you more challenging. It took hours of online searching to find a workout that fits my ability but that also avoids an annoyingly smarmy monologue or off-the-wall comments about hairstyle or the leader’s latest manicure. (Not kidding.) I ended up sampling the beginner clips from this list.
Taking a bricks-and-mortar class may be the best option for maintaining motivation, but also for feedback and advice on proper form and avoiding injury. Check out the background of the person leading the class. Barriers to entry are low, so anyone can teach yoga with a few hours of training. You’ll want someone with experience and many years of practice in the discipline.
“To my mind, a good teacher always asks, ‘Are there any injuries or conditions I should know about before we get started?’” writes Julie Corliss, editor of the Harvard Health Letter. She also advises checking out a few different classes to find a good fit.
You say that you and your partner use manual and oral stimulation, since you’re no longer able to have intercourse. Your partner requires extended stimulation, and you’re wondering what might help.
Stronvivo is a nutritional supplement developed for men’s cardiovascular health; it’s been found to significantly improve sexual health--because circulation is integral to arousal and orgasm. It is used for both male and female sexual health, improving both desire and function (ability to arouse and orgasm). I’ve had many women report improved ability to orgasm, and the clinical trials report the same for men.
The other factor to consider is medications that may be interfering with orgasm, or hormonal factors, like low testosterone. I’d strongly recommend a conversation with his physician, if he hasn’t already had one, to see whether there are health factors to consider.
You say you’re using a vaginal estrogen cream, and using Kegel weights with an aloe vera gel. You’ve had two yeast infections since you started using both.
If you are fairly new to using estrogen vaginal cream, it may be the cream that is causing the vaginal yeast infections. The estrogen cream lowers your vaginal pH (and a lower pH is a healthier status; here’s a summary of healthy pH levels) over the first 8-12 weeks of use. The transition from the higher pH (atrophic) to the lower pH puts women at risk for yeast infections. This should not persist, and in the end the estrogen cream is likely to be beneficial to you.
Sex after menopause can be challenging. This website and my medical practice is dedicated to addressing those challenges, so topics like dry vaginal tissue, pain with intercourse, loss of libido get a lot of press here at MiddlesexMD.
But for once, let’s turn the picture on its head. Let’s look at postmenopausal sex from the sunny side of the street.
Sure, menopause isn’t for the faint of heart. It’s a hormonal roller-coaster with a chaser of unpleasant side-effects. Sex can become collateral damage during all the turmoil.
But the big picture? The view from the top of the hill? Not so bad at all. In fact, depending on your inner resources and resolve, both sex and life after the big M can look pretty darned sweet. Some women even report experiencing a resurgence of desire, sort of golden age of post-menopausal sex.
Several elements tend to coincide during those post-menopausal years that contribute to a more serene, predictable life and the potential, at least, for a renewal of romantic zest. For example:
Granted, aging comes with challenges, and they can be unpredictable. But growing older and staying sexy is more about your attitude, and the resources you bring to bear than what’s happening below your neck. “So here’s the big reveal,” writes Barbara Grufferman in this article. “After 50, we’re at a sexual crossroads, and need to make a choice: We could go through menopause, shut down that part of ourselves, lock the door and throw away the key. Or we could embrace this new life with a sense of freedom and fun…”
So that’s the thing: it’s a choice. There are no wrong answers (unless they hurt your partner); instead, you have lots of options. Barriers to good sex are very fixable, both for men and women.
Here’s a list of simple things you can do to enjoy these golden sexual years to the full:
According to the experts, the most dependable predictor of good sex after menopause is good sex before menopause. And if it wasn’t so great before, time’s a-wasting. You can apply your hard-won life skills and your intimate knowledge of your partner to begin addressing the issues that stand in the way of intimacy and a solid sex life.
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.
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!
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:
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.
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.
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.
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.
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.
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.
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:
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!
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.
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.
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.