One of the benefits of my work with MiddlesexMD is the networking that makes it more likely that I’ll run into medical information, over-the-counter products, articles and books that could be helpful to my patients, and, of course, the interesting conversations that turned into our podcast, The Fullness of Life.
I received an advance copy of Love Worth Making: How to Have Ridiculously Great Sex in a Long-Lasting Relationship, by Stephen Snyder, MD, a month or so ago. Steve is a couples therapist, psychiatrist, and writer, as well as associate clinical professor of Psychiatry at the Icahn School of Medicine at Mt. Sinai in New York City. While I’ve met him—so far—only via email and his written words, I know we share some perspectives: that intimacy remains important to us no matter what our age, that men and women do have some differences in their approaches to love-making, and that there’s nothing wrong—and lots that’s right—about seeking tools that help us!
I think it’s useful to hear men’s perspective on sexuality, too, so when Steve offered to contribute to this blog, I accepted! Read on for more from Stephen Snyder, “sex therapist in the ‘hood.”
Several years ago, a merchant in my neighborhood learned that I was both an MD and a sex therapist. The next time I was in his shop, he asked me if I could get him some Viagra.
“How long have you had erection problems?” I asked.
“I don’t,” he answered. “But my wife and I have been married for 30 years. To tell you the truth, sometimes I’m too tired or preoccupied to get hard without the Viagra.”
What was this man’s problem, exactly? He wanted to have sex with his wife, even though he wasn’t feeling that strongly turned on. Evidently there were other reasons he wanted to do it.
Sound familiar? Of course: He wanted to make love like a woman.
Women can have sex with their partners any time they want. They don’t have to be very excited. Sure, some lubricant might be required, especially over 50. But the absence of peak excitement isn’t necessarily a deal-breaker.
A woman can make love for other reasons besides strong desire. To feel close or emotionally connected to her partner. To promote loving feelings. Or just for the simple pleasure of the experience. Even occasionally to keep a partner happy, even though she might be too tired or preoccupied to be really into it. A useful book on the subject calls it “good-enough sex.”
One wouldn’t want all one’s sex experiences to be like this. But once in a while it’s okay. Especially if the alternative is not to make love at all. If there’s one thing that sex research repeatedly shows about successful long-term couples, it’s that they keep having sex even when if the sex isn’t always earth-shaking. The ritual itself is important.
Men traditionally haven’t been able to do sex very easily under conditions of lower arousal. Especially over 50, when it ordinarily takes more stimulation to stay hard than it did at 20. If a man, for whatever reason, hasn’t been strongly turned on, conventional sex hasn’t usually been an option for him.
Viagra changed all that. Since the blue pill came on the market in 1998, a man can take Viagra and have sex even if he’s tired or preoccupied and just wants some loving and affirmation but isn’t feeling peak excitement. In fact, just having a good erection can help a man feel more in the mood.
There is often strong partner resistance to a man’s boosting his erection through chemistry, though. Women especially are used to the affirmation that occurs when a man gets hard (as Mae West famously put it) simply because he’s “happy to see her.” It’s worth it for a man to communicate that he needs sex for closeness and affirmation and pleasure as well. Just like she does. And that worrying about his erection just gets in the way.
Some couples worry whether taking Viagra under such conditions is a wholesome or natural thing to do. If it just takes more sexual stimulation now to keep him hard, wouldn’t it be more natural to simply intensify the excitement?
Maybe, but not necessarily. Intensifying excitement sounds like a great idea. But in practice, having to do things to get the man hard enough can be a bit of a burden. And it can take time, sometimes so much time that the moment is lost.
Sound familiar? Of course. It’s the same predicament that women find themselves in when they can’t get lubricated or can’t climax. Deliberate efforts to manufacture excitement often backfire. They usually aren’t very erotic.
My advice? It depends on the couple and the situation. But sometimes Eros is best served by taking the Viagra. Then a man can stop worrying about his erection, and get back to making love.
Sometimes it’s best for a man once in awhile to make love like a woman.
The loss of hormones (estrogen and testosterone) with a hysterectomy and bilateral salpigoophorectomy (removal of ovaries) is definitely a “hit” to sexual function for women (I assume based on your message that your ovaries were removed). The genitals are, as we say in medicine, abundant with hormone receptors. In other words, hormones play a big role in the health and function—both urinary and sexual—of the genitals. So now, moving on without those hormones, what to do?
For most women, it’s direct stimulation of the clitoris that leads to experiencing orgasm. In the absence of estrogen, there is less blood supply, and, in turn, loss of sensation and ability to arouse or orgasm.
This can also be a time to consider treating the genitals with prescription treatments such as localized estrogen or the non-estrogen options, Osphena or Intrarosa. Using testosterone off-label can help women with arousal and orgasm as well.
I’d encourage a conversation with your healthcare provider to see if there are options that may be helpful for you.
Good luck! I’m glad to hear that your husband is supportive in addressing this frustration for both of you!
As we’ve said (many times) before, our sexual responses are complicated and unpredictable. And this becomes especially true once we’ve embarked upon this menopausal transition. That doesn’t mean we can’t respond sexually anymore, just that we respond differently from men and differently even from the way we did before.
Way back in the 1960s, Masters and Johnson, the groundbreaking sexologists, developed a graph of the sexual response cycle. It was a simple, linear depiction that purported to track both men and women from arousal to afterglow in four stages—arousal, plateau, orgasm, and resolution. Sort of like a visual depiction of the wham-bam-thank-you-ma’am version of sex that women used to think was normal.
It did not contain a lot of room for nuance.
Fortunately, concepts about how we respond sexually have evolved over the years. Lately, Rosemary Basson, professor of psychiatry at the University of British Columbia, proposed another model of how women, specifically, experience sex. Guess what? It’s different from men. Her graph is circular. It includes elements that previously weren’t linked to sex, like relationship satisfaction and self-image, and our previous sexual experiences. It leaves room for skipped steps and a non-linear response to sex. This woman gets us.
Take feeling desire, for example. Basson’s model doesn’t get all hung up on desire. You may not feel spontaneous desire—the old “horny” thing—the way you used to. Or maybe you’ve never felt horny. According to a 1999 study from the University of Chicago, fully one-third of women never feel desire. “[Women] may move from sexual arousal to orgasm and satisfaction without experiencing sexual desire, or they can experience desire, arousal, and satisfaction but not orgasm,” according to this article.
You may not feel desire until you’ve begun to have sex; you might not feel desire even then. You might not feel desire even if you orgasm.
Likewise, for a lot of us, sexual satisfaction doesn’t even depend on having an orgasm, necessarily. We may have lovely, satisfying sex because it satisfies our partner and affirms the relationship and enhances our feeling of intimacy. Or, we may engage in sex for negative reasons, such as not wanting to lose a partner or avoiding the unpleasantness of turning him down.
Basically, Basson’s work tells us that however we experience sex that works for us and our partner is good sex. We may not “feel like” sex (experience desire), but once we get into it, desire might come tripping along like a puppy on a leash. Or, it might not, but the sex might be good anyway.
According to the literature, the sex that seems to work best for most couples is light-hearted, flirty, playful sex. It isn’t rushed. It has nothing to prove. It’s a mature, evolved celebration of the fact we’re still here, still loving each other. It’s the kind of sex worth working for.
So, let’s give ourselves a break. If we’ve been honest with ourselves, our sexual response very often depends on stimuli that has little to do with sex—how safe and happy we are in our relationship; how long we’ve been in the relationship; how we feel about ourselves (confident, sexy, desirable; or fatigued, stressed, distracted); whether sex has been painful (it’s hard to look forward to an experience that’s associated with pain).
The most important thing that’s necessary for sexual satisfaction in your relationship is the willingness to pursue it in whatever way works for you.
Oh, and the more sex you have, the more you want it. There are lots of ways to make sex comfortable after menopause: That’s what this website is all about; lube up and laissez le bons temps rouler.
The sexual arousal creams and gels are effective, and beneficial to most women who use them. Like our category of “warming lubricants and oils,” they typically use an ingredient like menthol, mint, or pepper to stimulate circulation, which increases responsiveness during intimacy. Read the instructions for the product you intend to use, to be sure you understand whether it’s for internal or only external use; lubricants are generally safe for internal tissues.
Arousal and warming products have the potential to cause some irritation for those women with significant atrophy, or thinning of the vulvovaginal tissues. I recommend applying a small amount to the genitals in advance of sex to make sure it’s comfortable and pleasurable.
You describe having been on bioidentical hormones for a number of years, as well as having had a complete hysterectomy. There are a number of variables that contribute to this mystery.
A couple of thoughts: Are you using testosterone with your hormone therapy? The ability to arouse and orgasm, as well as drive, is influenced by testosterone for some women. Not all women get an improvement in sexual function with the use of testosterone. If you aren’t using testosterone, you may want to have a conversation with your provider about adding it. Virtually all women over 50 have low testosterone, and having ovaries removed is a big factor in low testosterone.
Second, are you using compounded hormone therapy (HT)? I see so much variation in the dosing and absorption of compounded HT that I almost always recommend a pharmaceutical bioidentical HT. I just see so much more consistency in symptom relief.
There is also a relatively new supplement, called Stronvivo, that I have had some great successes with women. They’ve used it--and it’s been tested--for improved sex drive, lubrication, and more. A neuropsychiatrist in my community is recommending Stronvivo for improved memory, too!)
I hope some combination of these suggestions solves your mystery!
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.”
Autumn can be a tremendously busy time of year when work ramps up and social obligations resume. Or it can herald a return to peaceful calm after summer frenzy.
Full disclosure: There’s nothing peaceful about autumn for me! My appointment calendar is booked solid. No fewer than three healthcare conferences are on MiddlesexMD’s schedule in the next five weeks. That’s almost a rockstar schedule! (Well, maybe an aging rock star.)
So, whether your summer is an interlude or a frenzy, autumn is nonetheless an opportunity to reevaluate your relationship, sexually speaking, and recalibrate your sizzle, if necessary.
Long-term relationships have two (at least) universal pitfalls. One is boredom; the other is neglect. Occasional boredom is the almost inevitable result of familiarity and routine. It’s the same-old, same-old. It’s our guy in oversized sweatpants with a three-day scruff; it’s us in our stained muumuu and uncombed hair. And it’s the sexual routine that is as exciting as day-old coffee.
Hard to recall those days when we could hardly wait to rip the clothes off each other, hey?
Add a stressful job, social obligations, aging parents, kids in high school or university, and the absolute last thing on our minds is sex. The first thing is sleep. So, maybe we don’t even know if we’re bored because our sex life is over there in the corner gathering dust.
“As therapists, we can vouch for the fact that when people get out of the habit of loving in a sexual way, it can be extraordinarily difficult to get back into it,” writes therapist Christine Webber and Dr. David Delvin in this article.
Your assignment, should you choose to accept it, for this autumn is to reinvigorate romance, and ultimately, your sexual relationship with this person who, once long ago, made your heart beat faster.
Notice that there’s a hint of obligation here. A robust sex life might begin with spontaneous combustion, but it requires regular and conscious refueling to keep the flame alive over the long haul.
So, the first step is to want to revive your sexual relationship badly enough to make the effort and to commit to tending the flame. Here are some tips to get started.
Anticipation is a powerful aphrodisiac, and it’s one of the first casualties of a long-term relationship. “…living together…can take the anticipation out of sex. And anticipation is not just utterly delicious in itself; it's a useful tool for heightening your passion during the act—when you finally get to it,” write Webber and Dalvin.
You can heighten anticipation by:
One woman writes: “My husband resisted getting a cell phone for years. After becoming a small business owner, he finally caved and bought one. …After I had sent him a couple of steamy texts, he came home and said, ‘Boy, I never thought I'd say this, but I sure love cell phones!’ ”
Play. You’re only limited by your imagination here. Your date night could involve a variety of role plays: Arrange a tryst at a local bar. Arrive separately and “meet” each other. He (or you) might have conveniently reserved a room nearby. Go to a romantic movie separately and meet in the back row—make out just like you used to.
Here’s a list of adult games for both spice and romance, and honestly, they sound like fun!
Do it his way. Focus totally on pleasuring your partner. Do exactly what he wants—even if it’s not your cup of tea. Your task is to lovingly provide unforgettably erotic experience. Plan to fill in the gaps in case your partner’s imagination runs dry. Next time it’ll be your turn.
Change it up. Nothing beats boredom like a change of pace. Try different times—lovemaking in the morning, an afternoon delight. Do it in unfamiliar, maybe even [slightly] dangerous, places—on the floor in front of the fireplace, in your back yard at night, in the bathtub.
Get away—or stay at home. It’s always fun to make reservations for a weekend getaway—a nice hotel with an in-room Jacuzzi. Dinner by candlelight. A sexy, maybe erotic, film. Room service breakfast in bed.
But it can also be delicious to spend a weekend away—at home. Clear your calendar. Turn off the electronic gadgets. Get the cleaning and laundry done ahead of time. Stock up on luxurious and tasty treats that may also be known for their quality as aphrodisiacs.
Ever since Flibanserin was shelved after FDA rejection, the search for the next drug to treat lack of libido in women has been mighty low-key. To be sure, there were legitimate concerns about Flibanserin’s effectiveness, but as I’ve said before, we need more treatment options for women who suffer from hypoactive sexual desire disorder (HSDD).
Now, three years later, initial trials on another pink Viagra drug, which are actually two drugs (Lybrido and Lybridos), are just winding down. The results look “very, very promising,” according to Adriaan Tuiten, the drugs’ developer. If all goes well in the next phase of clinical trials, a pink Viagra could be on pharmacy shelves by 2016.
And that would be something to celebrate.
As I mentioned in my last post, HSDD is common; it’s complex; and it has confounded therapists and researchers for decades. Unlike pills for erectile dysfunction, low libido in women isn’t just a matter of hydraulics—increasing blood flow to the genitals (although it’s partly that).
Therapists and physicians have debated long and hard over female sexual desire—what creates it; what kills it; even what it is. Sexual desire probably has as much to do with our brains and our emotions as it has to do with our plumbing. And, possibly, desire may even be connected to the way women are hard-wired for sex, commitment, and monogamy.
It appears that women like novelty maybe even more than men. And while women don’t tend to be more promiscuous than men, they do tend to fizzle out, sexually speaking, more quickly and persistently within long-term relationships. They just lose interest.
“Sometime I wonder whether it [HSDD] isn’t so much about libido as it is about boredom,” says Lori Brotto, a therapist who has worked extensively on female libido, in this article in the New York Times magazine.
It’s also about loss of hormones that we experience—right about now.
This doesn’t mean that women who suffer from loss of libido don’t love their mates. It doesn’t mean that they can’t become aroused or even experience orgasm. It does mean that the sexual attraction, the heat and fizz, the interest in being sexual has waned or disappeared.
You know, the old “not tonight, dear. I have a headache” routine.
Make no mistake, for many women this is a real heartbreak. “How much easier it would be if we could solve the problem by getting a prescription, stopping off at the drugstore and swallowing a pill,” writes Daniel Bergner, author of the forthcoming book What Do Women Want?
This next frontier may be attained if Tuiten’s sister-drugs for HSDD —Lybrido and Lybridos—continue to be as effective as early trials suggest.
The two drugs affect three chemicals thought to be involved with sexual desire and arousal in women: testosterone, dopamine, and serotonin. But each drug takes a slightly different approach.
Both have a testosterone coating that melts in the mouth and enters the bloodstream quickly. Lybrido then works something like Viagra, increasing bloodflow to the genitals, which may heighten a woman’s awareness of her own arousal, releasing a resultant cascade of dopamine, the neurochemical of passion, in the brain.
Lybridos, on the other hand, use an anti-anxiety drug, called Buspirone, instead of the Viagra look-alike. After the testosterone rush, Buspirone temporarily suppresses the production of serotonin, a “higher order” neurochemical that creates feelings of well-being and self-control. Squash the voice of reason (serotonin) and perhaps passion (dopamine) will gain the upper hand. Or so the thinking goes.
Preliminary results from these trials were recently published in The Journal of Sexual Medicine. The next round will involve a much larger study.
“Perhaps the fantasy that so many of us harbored, consciously or not, in the early days of our relationships, that we have found a soul mate who will offer us both security and passion, till death do us part, will soon be available with the aid of a pill,” writes Bergner in the Times article.
In the beginning, there was passion. Your feelings were almost painful. You wrote long letters and sent silly gifts and spent hours in whispered conversations on the phone. A lifetime ago. Remember?
Then came the long familiar years. You settled into a cozy, secure routine. You finished each other’s sentences; you knew the next move, the habits, the vulnerabilities, the quirks and preferences.
But what happened to the passion?
Psychotherapist Esther Perel has spent her career studying the sexual language of long-term, committed couples. She’s pondered the dynamics of the love/desire dialectic, and she’s identified the qualities that keep the sexual spark alive over the years. In a recent talk, she discussed her work with exceptional lucidity. You may intuitively know what Perel has to say, but few of us have articulated it so clearly. In any case, it’s good to be reminded—and challenged.
Desire and love are paradoxical. They’re mutually exclusive. Love, says Perel, is to have. It’s associated with security, with safety, with roots and foundations. To love is to know the beloved and to be known. But this contented intimacy isn’t a necessary component of good sex, “contrary to popular belief,” says Perel.
To desire, on the other hand, is to want. Desire craves adventure, novelty, risk. We desire mystery, the unattainable, the 50 Shades kind of guy.
\Trouble is, we want both love and desire. We want security and passion. Intimacy and mystery. Safety and risk. So how can these opposing drives coexist in a marriage? How can we settle into the mature love of a long-term relationship without losing the hungry edge of desire that brought us together in the first place? How can we achieve the ideal of a “passionate marriage,” which fans the flame of desire within the intimacy of commitment?
As she studied couples around the world, Perel asked them when they found themselves most attracted to their partner. She heard variations of the same theme:
In these situations, there is a shift in perspective from the familiar to a sense of separation and distance. It’s the Proustian “voyage of discovery [that] consists, not in seeking new landscapes, but in having new eyes.”
Desire is a dialog we have with committed love. It’s a duet, a dance. The dynamic may be paradoxical, but both are necessary if a long-term relationship is to remain vital. It’s the language of poetry and mystery rather than of process and technique. Desire is more complex than bedroom gymnastics.
From her experience in studying and counseling couples, Perel has distilled several qualities that erotic couples seem to have in common. These aren’t on many “how-to” lists; they have more to do with essence than with activities. They may not be easy to incorporate because they’re not as straightforward as establishing a “date night.” But the concepts she delineates are worth some thought.
“Committed sex is premeditated sex,” says Perel. “It’s willful. It’s intentional. It’s focus and presence.”
To hear Perel’s talk in its entirety, visit the TED website here. This twenty minutes may be the best gift you could give your relationship today.
Diabetes has slightly more impact, statistically, on men's sexual function than on women's, but about half of both are affected. There are multiple reasons, most likely, which include neuropathy (impaired nerve function), vascular disease (narrowing of blood vessels for less circulation), and possible psychological issues. In women, that combination translates into lower interest, slower arousal, less lubrication, more difficulty experiencing orgasm, and the possibility of pain with intercourse.
As you often read, diabetes is a rapidly growing epidemic in the U.S., with obesity as the number one risk factor for developing the disease. Once again, maintaining overall health is vitally important to preserving sexual health.