You say you’ve read about oral stimulation in She Comes First. Congratulations on continuing to learn about sexuality and your own body!
Oral stimulation is for everyone: all ages, all stages. It’s personal preference, or maybe not. I have a number of patients who only experience orgasm with oral stimulation.
Like so many things sexual, there are many variations, many preferences, and no “one size fits all.”
Holidays are a booby trap for intimacy. So much to do; so little time: cards, cooking, cleaning, decorating, gifting, partying, shopping, visiting. Makes me exhausted just to think about it! Little wonder, then, that the first casualty of holiday celebrating is usually our closest relationship. It’s just too easy, either to vent our stress on our significant other or to ignore the daily interactions and kindnesses that lubricate the wheels of intimacy.
So, to help keep those wheels humming despite the holiday frenzy, let’s explore a few creative ways to share the love with your honey. Actually, when you think about it, Christmas is delightfully sprinkled with sexy innuendo. So let’s think about it.
I hope this list gives you some ideas to work from. If nothing else, I hope you resolve to navigate this special season with an eye to preserving your own peace of mind and nurturing your relationship.
Bladder health may be far from the most riveting of conversations, but trust me, a bladder that behaves itself will make your life a whole lot more enjoyable, and that includes your sex life, as well.
As we discussed in the last post, bladder misbehavior in the form of incontinence and urinary tract infections (UTIs) is a common female complaint, and it tends to become more common and more troublesome as we age. This is because decreasing estrogen affects genital tissue and muscles in unhelpful ways.
You don’t need to check out adult diapers just yet, however. Not only are treatment options available, depending on the type of incontinence you have, but you can develop some common-sense bladder health habits that will tune up that tired organ and may even roll back some of the age-related changes.
Despite your attention to good bladder health, you may still experience bothersome levels of incontinence and UTIs. The next step is to talk with your doctor. Studies show that most women avoid this conversation because, well, it’s embarrassing. Let me assure you that we’ve heard it all, and incontinence is an incredibly common female issue. This isn’t something you should endure. Treatments are available, and they do work.
Depending on the type of incontinence you have, (urge and stress incontinence are the two major sub-types), treatment options could be very simple. With bladder training, for example, you set a timer and wait for increasingly longer periods before urinating to “retrain” the bladder (and yourself). This method coupled with Kegel exercises can cut urge incontinence problems in half, according to the National Institutes of Health.
There are a number of medications, including some new ones, that are very effective in treating urge incontinence. Your health care provider can help you weigh the options.
Since stress incontinence is more commonly caused by wear and tear on the pelvic floor (by childbirth, for example) as well as by normal aging and hormonal loss, medications are less effective in treating it. Topical estrogen, however, is a good option for rejuvenating tissue in the entire genital area, urethra included. It isn’t absorbed systemically, so it’s a good option for those who want to avoid extra hormonal exposure
A common and minimally invasive surgical procedure involves inserting a tiny mesh sling to support the urethra. This procedure is effective in over 85 percent of cases.
For most of us, some level of incontinence is an annoying fact of life. But it shouldn’t compromise our quality of life or cause undue embarrassment or anxiety. If you find this to be the case, it’s time for a talk with your doctor.
And what, you ask, does my bladder have to do with sex?
Good question, but here’s the thing: When you think about it, all our sexual bits are tucked in a very tight space with all the “other” bits we use for elimination. They all cohabit the same anatomical real estate and pass through the same muscular sling (pelvic floor). If you question the wisdom of our anatomy, pity the poor hyena, who copulates, urinates, and gives birth—with great difficulty—through the same tube.
Since all those organs are clustered in one anatomical region, they are also all sensitive to any change of flora or pH balance or hormones that might happen in that space. In fact, what we now refer to as the genitourinary symptoms of menopause (GSM) is an umbrella term for the hormonal changes which affect the whole enchilada—pelvic floor, bladder, vagina, and all the associated tubes and musculature. (The bowels aren’t included, but they can also be affected by age and hormonal change.)
So, as vaginal tissue becomes more fragile due to loss of estrogen during menopause, so does the labia and the urethra (the tube from the bladder through which we urinate). Specifically with regard to the bladder, GSM exacerbates two extremely common female complaints: urinary incontinence and urinary tract infections (UTIs).
If you’ve had kids—and maybe if you haven’t—you’ve probably experienced the nearly ubiquitous stress incontinence of the cough-sneeze-pee variety. A second type of incontinence is overactive bladder (OAB) or urge incontinence. This is when you feel the need to pee suddenly, frequently, and urgently. In both cases, small—and sometimes large—leakages may occur.
Both conditions can either commence or worsen with menopause, and either can cause you to urinate a little or a lot during sex, usually with penetration or orgasm, when all the nerves in the area are stimulated.
Which could really dampen the mood.
Research on the effect of incontinence on sex is scarce, and honestly, that effect would seem pretty intuitive. Studies that have been conducted indicate that incontinence has a negative effect on sex (duh!)—and on life in general. The embarrassment and anxiety of constantly having to worry about peeing your pants certainly puts the kibosh on quality of life—and that embarrassment doesn’t stop at the bedroom door.
In one small study, every woman with OAB syndrome all expressed anxiety over its effect on their sex life, whether or not they were actually incontinent during sex (coital incontinence). Just the worry about whether they would pee during an orgasm was enough to create a psychological barrier to sex. The worse their condition, the greater the negative impact on sex.
“Overactive bladder with or without incontinence negatively affects women's sexual health, reducing sexual desire and ability to achieve orgasm,” the study concluded.
Urinary tract infections (UTIs) are the second sucker-punch to libido that accompany and can increase with age and menopause. Again, it’s all part of a syndrome in which loss of hormones makes our genitourinary tissue more fragile and prone to breakdown and, thus, infection. Our female anatomy—short urethra in a warm, moist location near our other orifices—creates an inviting greenhouse for bacterial growth. Ironically, even sex can cause a UTI because it invites the migration of bacteria from one spot to another.
But take heart! As with most things menopausal, prevention techniques and treatment options are available. There are ways to mitigate the effects of GSM on the bladder and ways to prevent them. Not perfectly. Not always. But neither do you have to soldier on alone and in silence. That’s the kind of awareness that Bladder Health Month is all about.
Many of us are very goal-oriented. We like to make lists and to tick items off those lists. We like order; we don’t like chaos.
Unfortunately, life is messy and sometimes chaotic.
At no time is this truer than during the holidays. All the demands of the holidays—the shopping, cooking, partying and gathering—will simply be heaped on top of our already overflowing schedule. We know that the price we pay will inevitably be snappishness, exhaustion, maybe the scratching of old scabs and regurgitation of old hurt.
In the interest of helping all of us not only to survive, but maybe even to enjoy the holidays, I offer you a mini-tutorial on a practice that has been known to help everyone from cancer patients to Fortune 500 executives. It’s even known to improve our sex lives, which is why we highly recommend the practice of mindfulness on our website.
Mindfulness is a straightforward concept. It’s developing the ability to pay attention to the moment—not to zone out, but to develop a facility of focused attention, without judgment or emotion, on the present. Mindfulness was a Buddhist concept, but in 1979 Jon Kabat-Zinn, a psychiatrist at the University of Massachusetts Medical Center, adapted and developed it into a formal eight-week program for patients “who weren’t being helped” by traditional medicine. His program incorporates meditation, mindfulness exercises, and yoga.
The results were impressive. Patients experienced less pain, and they healed faster. The practice relieved stress and improved the immune response. The concept of mindfulness meditation quickly seeped into the broader zeitgeist.
Now, I know that it’s one thing to read about a spiritual practice, helpful as it may be, and entirely another to actually incorporate it into daily life, especially in the midst of holiday frenzy. The essence of mindfulness, however, is simple and almost intuitive. Best of all, it takes almost no time. You can practice mindfulness while you’re rolling out pie crust or brushing your teeth. It quiets our “monkey mind” and brings us back to the moment, which, after all, is the only moment we really have.
“Life is available in the here and now, and it is our true home,” writes Thich Nhat Hanh, a Buddhist monk and globally famous spokesperson for mindfulness meditation.
Mindfulness practice doesn’t take effort, and it doesn’t take time. It just requires a focusing of thought and awareness. The basic meditation is to focus on your breath: Just paying attention to breathing in and breathing out. Your breath doesn’t have to be long or short. You just have to follow your in-breath and your out-breath.
You can think, Breathing in, I’m aware of my body; breathing out, I release tension in my body. You mentally pay attention to any parts of your body that are tensed—your lips, your neck, your back—and consciously relax that part. When you wait in line or stop for a light, you have a bit of time to practice this focus and release. And then smile, says Thich Nhat Hanh.
This principle can be applied to whatever you’re doing: cooking, cleaning, taking a shower, taking a walk. You bring your attention lightly but completely to the activity you’re engaged in. You don’t think about the next thing you have to do or the fight you had with your spouse this morning. Those thoughts are like the clouds crossing a bright, blue sky. You observe them without emotion or judgment and let them go, returning to your focus on your breath or your walk or the pie crust.
As you practice mindfulness, you may become conscious of the moment before you react to something. When you are aware of that moment, the moment before you react, then you have a choice about how you will react, whether in anger or kindness, fear or trust, passion or forbearance. If you’re aware, then you have a choice.
"Between stimulus and response there's a space, in that space lies our power to choose our response, in our response lies our growth and our freedom," writes Victor Frankl, Holocaust survivor and author of Man’s Search for Meaning.
I’m thinking that if ever there was a good tool for avoiding those uncomfortable confrontations during the holidays, this might be it. If you’re aware of the moment of stimulus, when your brother makes a snarky remark about your son’s tattoos, for example, then you are given a moment of choice about how you’ll respond. And a moment to breathe in, breathe out without tension or judgment.
Even though it’s effortless, developing this practice isn’t easy. I guess that’s why it’s called a “practice.” I do know that improvement, however incremental, helps me to live with gratitude and gracefulness.
And during the holidays, I simply can’t get enough of either.
As Thich Nhat Hanh writes: “The real miracle is not to fly or walk on fire. The real miracle is to walk on the Earth, and you can perform that miracle at any time. Just bring your mind home to your body, become alive, and perform the miracle of walking on Earth.”
Amen to that!
To know the ultimate solution for treatment of painful intercourse, it’s important to know the exact cause of the pain. If it is vulvovaginal atrophy, then a vaginal estrogen, like Estrace vaginal cream (which you say you’re using), or Osphena, a non-hormonal oral medication, should be helpful. But not every option works for 100 percent of women, so if this is the diagnosis and you are not responding, another product should be considered.
There may also be another diagnosis apparent after a thorough exam. The condition you describe may be vulvodynia, which is referred to by a variety of names including provoked vulvodynia, localized vulvodynia, or vestibulodynia. I normally hear a description of burning, tearing, sandpaper-like, usually near the opening of the vagina.
Another cause of pain can be vaginismus, which results from too much tone of the pelvic floor muscles and results in painful intercourse. It’s the involuntary spasm of the muscles, which prevents or limits penetration.
Please persevere to get both a diagnosis you trust and a treatment that’s effective for you!
You say you’re past menopause, which is defined as a year without menstruating. Intercourse has become painful, and occasionally you have some bleeding afterwards.
The condition that leads to painful intercourse in menopause is vulvovaginal atrophy, now called genitourinary syndrome of menopause. The absence of estrogen leads to profound changes to the genitals. The vagina and vulva shrink, and the tissues are more dry, thin, and fragile. This leads to painful sex. Within five years of menopause, up to half of women have pain with intercourse.
Early in menopause, before the atrophy is advanced, vaginal moisturizers can be beneficial; they are considered part of prevention. But once the atrophy is more advanced, moisturizers are not enough.
You can restore health by adding a localized (vaginal) estrogen or using Osphena (an oral, non-estrogen treatment). Both of those options are prescription therapies that reverse the atrophy and restore health to the vagina, vulva, and lower urinary tract. A good lubricant is definitely important too, I recommend Pink, a silicone lubricant with aloe and vitamin E.
Occasionally, there can be an additional cause--beyond atrophy--for painful intercourse. A careful examination by a menopause care provider will help determine the exact cause and whether any additional treatment would be helpful.
Best of luck! With patience and persistence, most women can regain comfortable and satisfying intimacy!
It’s unpredictable what will come up when the MiddlesexMD team gathers. As the holiday shopping season approached, it was REI’s #OptOutside campaign, which encourages people to skip Black Friday shopping and get outdoors, that captured our attention. That seemed to align with my [very] frequent advice to women, especially as they approach and pass through menopause: Stay active! If you haven’t been active, get active! We thought we’d ask Kate Convissor, who “haphazardly maintains a blog about her own travels at www.wanderingnotlost.org,” for a guest blog post that might inspire you to get outside and get active.
I am camped in Bugaboo Provincial Park in British Columbia, Canada. There is only one trail that someone who doesn’t know a carabiner from a crampon could attempt, so that’s the one I set off on. A couple hours and a lot of calories later, I stumble from an aspen forest into, literally, Paradise. I am in a large meadow covered in kelly-green ice plant and dotted with wildflowers: bright orange Indian paintbrush, pearly everlasting, purple aster. Rivulets of blue water twist through the meadow. In the far distance, the Bugaboo Glacier flows around a rocky spire and down the mountain, imperturbable, as it has for millennia.
I am no extreme adventurer. I grew up in Detroit; my family was neither athletic nor outdoorsy. As a young mom, I spent more time looking out the window than venturing out the door. All that changed in my late 40s when my then-husband, two youngest kids, the dog, and I embarked on an 18-month road trip.
For the first time in my life, except for sleeping, I basically lived outdoors. I spent weeks in environments as foreign and varied as ocean beaches, deserts, mountains, prairies. My field guides became tattered as I paged through them to name trees, birds, and blossoms I had never seen before. I hiked for miles and learned the basics of survival—never leave without 1. Sufficient water; 2. A good hat; 3. Eye and skin protection; and 4. Enough time to get there and back before sunset.
That trip was fifteen years ago. The kids have grown up; the dog has died; the husband has moved on. But I have not lost my desire, almost my need, to be outside. I just like to smell the breeze, listen to the birds and the snuffling of creatures, and to stretch my legs on trails and country roads. It quiets the mind, aligns the cells, and soothes the soul. It keeps joints lubricated and muscles toned; it keeps blood pumping through clear arteries. If the information on MiddlesexMD is correct, it keeps life good and makes sex better.
Which brings me to Black Friday.
I am absolutely confounded when I hear about people camped in front of WalMart on Black Friday (Camped! When there are places to camp that will take your breath away!), fights in the aisles over a television set, or stampedes that actually kill people.
In the teeth of this feeding frenzy, REI, the giant outdoor gear store, has launched what has amounted to an anti-consumer movement: #OptOutside. On Black Friday, all the REI stores throughout the nation close, and every employee is paid to get outside for the day. All the rest of us are encouraged to participate.
This is the kind of commercialism I can really get behind.
I am in my mid-sixties now. Like all of us, I recognize that unless I keep moving, pretty soon I won’t be able to so easily. Keeping the mind and body limber takes some intentionality these days.
So this Black Friday, I challenge you NOT to drive to the mall, fight the crowds, buy stuff neither you nor anyone else needs. Why consume time, gas, and your own energy and peace of mind when you can be outdoors? Why not accept the #OptOutside invitation? Find a patch of earth that has some nature on it. Find a trail or a park or even a pleasant neighborhood. And walk. Just walk.
Then do it again the next day.
Me? I’m going to hike the Reid Lake Trail in a national forest just north of me. And you?
Can anyone guess what we have in common with female orcas (killer whales}?
That’s it. We share menopause with only two species on the planet, and both are whales: the orca (killer whale) and the pilot whale (which is technically a dolphin). All other mammals, including gorillas, chimpanzee, elephants, dogs, cats, and camels continue to bear young, albeit with decreasing frequency, until they die. No other mammal experiences literally decades of post-reproductive life.
Except us and the whales.
Of course, the big question biologists ask is, Why? From a Darwinian perspective, bearing young assures the continuation of the species. Decades of life without fertility makes no evolutionary sense. (According to biologists; we, on the other hand, might feel otherwise.)
Now, after decades of closely observing a specific pod of killer whales in the Pacific Northwest, biologists have greater understanding of the role female elders play in the whale community. The almost eerie parallels to our human experience have piqued the interest of scientists and writers, who think perhaps the way of the orca may shed light on human menopause.
For years, scientists thought human menopause was simply due to medical advances that enabled women to outlive their normal genetic lifespan. Without the intervention of modern medical technology, so the thinking goes, we too would bear children until we died, like our close mammalian cousins. Evolution, remember, favors traits that support the passing on of a species’ genes.
Enter the orca.
Female orcas stop calving in their 30s and 40s, but they continue to live for many decades beyond that—well into their 80s. “Granny,” the oldest of the Northwest orcas, is thought to be over 100 years old. After decades of observation, including hundreds of hours of underwater video, scientists began to understand that these old gals weren’t just freeloading on their sons and daughters. They were critical to their survival.
Orcas mostly hunt salmon, stocks of which vary, sometimes greatly, from year to year. It is the older female orcas that tend to lead the pods, and this is especially noticeable when the salmon stock is low. During lean years, the older females more frequently lead the clan. At those times, the accumulation of knowledge and experience by the older females give the orca a critical edge.
“That kind of knowledge is accumulated over time—accumulated in individuals,” said Darren Croft, professor of animal behavior at the University of Exeter in this article.
Studies of death rates were also revealing. The whale clans are matrilineal, with sons and daughters staying with the mother for life. Mature sons are so dependent, in fact, they are called “mummy’s boys.” They leave the clan periodically to mate, but they return to follow their mothers. When an older female dies, her sons and daughters are more likely to die as well. In fact, a son is eight times more likely to die within the year after losing his mother.
While these characteristics don’t exactly parallel human experience (we don’t tend to enjoy having our aging sons follow us around), they do point to the critical role of older females to the survival of the clan, whether whale or human.
Recent studies of hunter-gatherer societies reinforce this hypothesis. Given the long and costly job of raising human children to adulthood, grandmothers play a critical role in the well-being of the family, often taking on the role of forager-in-chief and caregiver for a daughter’s children.
It’s called the “grandmother effect.” Evolutionary biologists hypothesize that these contributions of an older woman offsets the decades of infertility. The grandmother assures that her genes are passed along by making sure that her grandchildren survive.
By no means do the grandma orcas take a back seat to the kids. They remain spry, vital, and active into their advanced years, maintaining their role as guide and coach. But the old gals have also been seen cavorting sexually with young males, presumably to teach them a thing or two about the birds and bees—and the cetaceans.
“Besides being the repository of knowledge about where to go in case of lack of food, they also lead very rich lives,” says Deborah Giles, director of the Center for Whale Research.
And so do we. This evolutionary state of affairs wherein we enjoy decades of vigorous, post-reproductive life while contributing to the well-being of our kin and the world in general is a pretty happy state of affairs, I’d say.
If the whales are any indication, far from being redundant, useless, or invisible, we continue to fill important and meaningful roles after menopause, which we have garnered through years of experience.
“We complain, women of my age, of becoming invisible, and it's true—you realize how very much you're defined by sexuality. But I have a sense—galvanized by stories about the killer whales—that now is the time when you become the person you really want to be," writes journalist Christa D’Souza, author of The Hot Topic, a book about menopause.
“The idea of women passing on information; the idea of wisdom with age—there's a beauty in that that is about something other than being able to reproduce.”
You describe a series of distressing events, including your stroke, a separation for your rehabilitation, and your wife’s loss of desire. You’ve sought help from mental health professionals, one of whom prescribed antidepressants for both of you.
I’m so sorry that after so many years of a great marriage and sexual relationship, you’re facing this difficult and complicated situation. It’s normal to grieve this loss of intimacy. Now you’re likely dealing with a combination of emotional and physical factors, and the antidepressants prescribed to help can also dampen desire.
I’d recommend that you seek a therapist specializing in sexual health. AASECT (the American Association of Sexuality Educators, Counselors, and Therapists) certifies specialists trained to address sexual concerns and offers a “locate a professional” page. Choose your state, check the “Therapists” box, and click “search” to identify a resource in your area.
A skilled therapist can help the two of you navigate this complex issue. Congratulations on your long-term commitment to your relationship, and I hope you do restore its full richness.