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.
Oh, I feel for you. You say you have pain (and no doubt other symptoms—like fatigue and depression) from lupus, fibromyalgia, and Sjogren’s syndrome. You see your lack of interest in sex becoming a larger problem in your marriage as the difference between your sex drive and your husband’s increases.
The first order of business is to find a health care provider with whom you can discuss this aspect of your health. The pain you mention may be generalized pain from the autoimmune conditions you have, or it may be pain with intercourse. Painful intercourse is nearly always a treatable condition, so addressing that if you experience it is critical.
The harder issue is the “desire discrepancy” you describe in your marriage. While the situation is not uncommon, your additional health issues add a degree of difficulty. Assuming any issues with painful sex have been addressed, there are some medications that can be helpful for low libido: Addyi, testosterone, and Wellbutrin, to name a few. Your health care provider can help you understand if any of these can be an option for you depending on your health history and other medications you’re taking.
For more about low libido, you can read this blog post on the emotional component and this one that includes an overview of the condition and common causes. It could be helpful to read these to have some terminology in mind when you meet with your health care provider.
The situation you describe might best be addressed with a (sex) therapist—perhaps not a dedicated sex therapist but one who has expertise in health-related relationship concerns. (Here are two blog posts on sex therapy: one I hoped would demystify it and one that explains how it works.) Your health care provider is likely to be able to direct you to someone with experience to assist you and your husband as you navigate this significant challenge.
Best of luck in reaching some common ground!
You say that your wife suffers from lichen sclerosus, a condition that creates skin tissue that is thinner than usual (and is a higher risk for postmenopausal women). Warming oils and lubricants, unfortunately, create discomfort rather than arousal for her. I'm not aware of an option in that category that would work for her, since the ingredients that make them effective--usually something minty or peppery--will almost certainly cause an adverse reaction.
Plain lubricants won't cause that reaction; those we include in our product collection should be well-tolerated by lichen sclerosus patients.
There are a couple of other options you and your wife could explore for arousal. The use of testosterone has been beneficial for 50 to 60 percent of the women in my practice who've tried it. Testosterone is by prescription and off-label for women, which means a discussion with her health care provider is required.
Other prescription options include localized estrogen, Osphena, or Intrarosa (a recently available FDA-approved choice). Any of these would increase blood supply by "estrogenizing" the genitals, which can improve arousal and orgasm as well.
Congratulations on undertaking this exploration together! Good communication and mutual support are so important to shared intimacy.
Okay. We’ve talked about sexual lubricants before. Many times. And for good reason. Vaginal dryness and the associated pain with sex, penetration, and sometimes daily life is possibly the #1 issue I deal with in my practice.
Insufficient lubrication during sex isn’t just a problem of menopause—many women experience it at various times of life—during pregnancy, with insufficient foreplay, or while on certain medications, for example. Or just because.
Fortunately, sexual lubricants are an easy, safe way to make sex more comfortable and fun.
One critical distinction: Lubricants are for use during sex to increase comfort and reduce friction. They coat whatever surface they’re applied to (including the penis and sex toys) but they aren’t absorbed by the skin, thus, they have to be (or naturally are) washed off. Moisturizers, on the other hand, are specially formulated to soften and moisten vaginal tissue. Like any lotion, they should be used regularly and are absorbed into vaginal and vulvar tissue. Moisturizers are for maintenance; lubricants are for sexual comfort.
Basically, there are three types of sexual lubricants: water-based, silicone, and a newer hybrid formulation. Each has unique characteristics and limitations. Water-based lubes are thick, feel natural, don’t stain, and don’t damage silicone toys. They rinse off easily with water. However, they tend to dry out more quickly (although they can be re-activated with water) and don’t provide long-lasting lubrication. Water-based lubricants may contain glycerin, which tastes sweet but can exacerbate yeast infections.
Silicone lubes are the powerhouse of personal lubricants. They tend to feel slick and last three times as long as water-based options. They’re hypoallergenic, odorless, and tasteless. They may stain, and they will destroy silicone surfaces on other equipment, so you can’t use silicone lubes on your expensive silicone vibrator. They wash away with soap and water.
Hybrid lubes, as the name suggests, have some characteristics and benefits of both water-based and silicone.
At this life stage, you can put away your coupons and dispense with frugality. Your vagina deserves the best! Not only have those tissues become more delicate, your vagina also has a finely balanced pH level that (usually) protects against yeast and bacterial infections. Cheap or homemade lubricants can seriously mess with tender tissue and that natural acidity.
Some lubes contain “warming” ingredients, such as capsaicin, the ingredient that gives chili peppers their heat, or minty, or menthol-y oils. They’re intended to enhance sensation, increase blood flow to the genitals, and create a “tingly-warm” feeling. As such, they’re good for foreplay and use on vulva, clitoris, penis, nipples, external vaginal tissue, but not internally if they contain essential oil.
Use warming oils and lubricants with caution, however, since delicate or dry vulvar-vaginal tissue may respond with a fiery-hot rather than pleasantly warm sensation.
Use only products recommended for vaginal lubrication—not baby oil, vegetable or essential oils, petroleum jelly, or saliva. (Note: Oil destroys the latex in condoms and leaves behind a film that is a bacteria magnet.) Look for organic, natural, and high-quality ingredients (we look for these for our shop).
Each individual (and couple) ends up with one or more faves when it comes to lubricants. So make this a fun exploration for the products that work best, both for solo and couple play. If you don’t like one lube, a different type or brand might be just the ticket; don’t give up on lubes altogether.
Because the options for various lubricants are legion, we’ve tried to narrow the field in search of only the most effective and safest products for our shop. We examine the ingredients and opt for the most natural and organic brands possible. We also look at the philosophy of the company that makes them. We’ve been known to do quite a bit of research “in the field,” as well.
In the spirit of experimentation, we’ve put together a selection of seven sachets of water, hybrid, and silicone-based lubes in a handy sample kit. You can give them a whirl without the investment in a full bottle of lube that ends up in your sock drawer.
New lubricant options appear with some regularity, and we evaluate and add them periodically. If you’ve found something you love, let us know; other women may be happy to learn about the option!
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.”
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.