September 29, 2016

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arousal ›   women's sexual health ›  


Q: Does exercise help libido?

You asked. Dr. Barb answered.Yes, exercise helps libido in a number of ways, both directly and indirectly. It improves general health and energy levels. It improves sleep and blood supply. And it improves self-image, too, which can make us feel more desirable and more in touch with our sexual selves.

I recommend that women add Kegel exercises to their exercise habits. Increased muscle tone in the pelvic floor increases orgasm response, as well as keeping our organs where they belong and preventing or minimizing incontinence. It’s a complete win!

So yes, get active or stay active. Your body will thank you.

September 15, 2016

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arousal ›   comfort ›   women's sexual health ›  


Q: How can I boost my desire and arousal?

You asked. Dr. Barb answered.

You say you find your partner attractive, you have a good relationship, and your gynecologist gives you a clean bill of health. And yet, you’re having trouble getting aroused. 

One consideration may be Stronvivo, a nutritional supplement that has been shown to improve sexual function for women (and men), including improved libido/desire and ability to arouse and orgasm.

Some women with libido concerns benefit from supplementing testosterone. This requires an assessment and monitoring from your physician or nurse practitioner, since it’s prescription only. Use of testosterone in women is considered “off label”, or non-FDA approved, and not all practitioners are willing to prescribe it for their patients.

At the same time, you say you’re experiencing less moisture. This is critical to address, because painful intercourse is, of course, not an incentive to desire! There are varieties of lubricants that can add playfulness as well as immediate increased comfort; regular use of a vaginal moisturizer can help you through perimenopause.

 I do know this issue can test relationships, and wish you the very best in finding a way forward! Be assured it’s possible.

Testosterone Therapy: Another Set of Socket Wrenches

I love options. Moose Tracks or Mackinaw Island Fudge? Mocha or machiatto? Phillips screwdriver or allen wrench?

Mostly, I like having options for my patients. At this awkward middle-age time of life, issues are complex and solutions are rarely straightforward. So I like to have a toolbox of treatment options to choose from. If one method doesn’t work, maybe another will.

To be clear, I always start with the most natural, straightforward treatment possible, postponing pills, prescriptions, and hormones. To this end, a healthy lifestyle is the first and most important contributor to a good sex life. Along with lavish use of moisturizers, lubricants, toys, and imagination.

But when these things fall short, it’s nice to have options.

Healthy lifestyle first and most important contributor to good sex lifeThat’s what testosterone therapy offers—another tool. Another treatment regimen that might fan a faltering libido and fading intimacy in an otherwise healthy relationship. Like any treatment, this isn’t a silver bullet or a magic pill. In fact, it’s controversial. There just isn’t a lot of research on long-term use or even on how testosterone functions in women. (Spoiler alert: a lot different than in men.) It isn’t FDA-approved, although it’s been prescribed “off-label” for decades in the US and is prescribed legally in Europe and elsewhere.

In women, testosterone is produced at much lower levels than in men, mostly in the ovaries and adrenal glands. As we age, and especially if our ovaries have been removed, testosterone levels drop sharply. This isn’t the only reason for diminishing sexual desire but it may be part of the picture. (In medicalese, a distressing loss of libido is called hyposexual desire disorder—HSDD.)

Since declining testosterone levels, menopause, and HSDD tend to happen in tandem, maybe a causal link exists among them, so the thinking goes. Obviously, it’s more complicated than that, but for some women, a little testosterone boost just seems to work. As a recent bulletin from Harvard Medical School states: “…in some but not all studies, testosterone therapy has been shown to be an effective treatment for HSDD in carefully selected postmenopausal women.” In my clinical experience, testosterone therapy improves libido, desire, and/or the ability to orgasm in about 60 percent of the women who take it.

So, what are those “carefully selected” qualities that make a patient a good candidate for testosterone therapy?

First, testosterone won’t cure difficulties in a relationship that may be contributing to intimacy problems. Other libido-killers include depression, fatigue, anxiety, certain medications, and the usual menopausal suspects: loss of estrogen, night sweats.

In the absence of physical or psychological factors, women who are distressed by their lack of libido (the classic definition of HSDD) might find relief with a little extra testosterone in their system. I monitor blood levels during treatment with the goal of restoring testosterone to the level you probably had when you were 25 years old.

Some women (about 20-30 percent of my patients) experience some added benefits, such as improved mood and more energy, while another 10 to 15 percent have less positive side effects, like unwanted hair growth or acne. And for about 40 percent of my patients, testosterone therapy isn’t helpful at all.

Testosterone can be safely applied topically; I usually prescribe a gel, the same FDA-approved topical gel that is used by men, but at one-tenth the dose, which I find offers a safe and consistent delivery of the medication.

For some women, testosterone is a game-changer and for others, not so much. Since the potential benefit is so positive and the detriment is minimal, in my opinion, testosterone therapy is a solid treatment option. A woman who’s tried it will tell her story in our next blog post.

A Watershed Moment for Women's Sexual Health

It may surprise you to hear a practicing doctor readily admit that there are vast fields of uncharted forest in human medicine.

I knew that when I began my studies, and now, many years later, I still find the constant learning that the discoveries my scientific sisters and brothers bring to my field my greatest hope and challenge. And sometimes it’s a source of frustration too, but today I’m focused on hope.

For quite a few weeks now I’ve been able to offer my patients something new. Addyi, the trade name for Flibanserin, the much talked-about prescription drug designed to treat Hypoactive Sexual Desire Disorder (HSDD), a disorder that I’m all too familiar with in my practice, a heartbreaking condition faced by so many of my patients and their loved ones.

But back to the question of advancements in medicine. When I think of this moment. I think of a parade of watershed moments in medicine. I know it may not seem like this to many people on the surface of it, but the approval of this drug, to doctors who serve women with sexual disorders, is HUGE. In my field it’s up there with, say, the dawn of anti-septic operating procedures. Think: we’ve only been washing our hands carefully before surgery since the 1860s. In the scheme of things, not that long ago! Or another watershed moment for women, the publication of Our Bodies, Ourselves by the Boston Women’s Health Collective in 1973, a book that changed everything, utterly. Or the Public Health Service Act of 1975, which made gender inequality in medical education illegal for the first time and propped open the doors for my own education… Finally.

And when I think of my ability to write Addyi prescriptions for my patients, that’s mainly what I think. I think…Finally! As hard as it was to get this one single drug for female sexual dysfunction (compared with 26 for men?) approved, and with all of the weight of its warnings and the hoops of physician training and the cost of it — despite the weight of all of that, through all of that — the FDA heard us. THEY HEARD US. 

And that is the win. 

So. Addyi is my new septic procedure. The one that will start saving lives immediately, one way or another. I can’t tell you what it means to me to have at least one arrow in my quiver for the women, LOTS of women, suffering, in my practice, because they WANT to want to feel the fullness of their sexual selves come alive. A basic human right, says the World Health Organization. A basic human right. 

(By the way, did you know that Joseph Lister, the inventor of septic operating procedures was ridiculed widely and run out of this country, had to work extra hard and fought a difficult uphill battle to convince people that, really, anti-septic procedures in surgery would save lives? True story… If people had only believed him right away…. )

The outcome of the past few years is a watershed, a turning point because through the process of approval, the FDA has gotten the message: They now completely understand that this previously misunderstood disease — or the complex of Female Sexual Dysfunction, is very real. These women are suffering. So are their partners. They deserve focus, research, discovery, and treatment. And judging by the most recent news that the FDA has recognized Female Sexual Dysfunction as one of the 20 key unmet medical needs in the United States, they will be getting it. 

HUGE.

Meantime, Addyi will help some of these women. Maybe your sisters or daughters. Some with Hypoactive Sexual Desire Disorder will improve with this treatment. At least they will know within a month or two of trying, and for those suffering, the option is available to them right now. 

These women will need to talk to their doctors about Addyi. Women who don't think they need it can help their sisters by asking their doctors about it, showing that it matters. Doctors will need to complete a short online training course to familiarize themselves with the new drug. It’s very short, and found right here. The sooner doctors get their training in, the sooner they can start prescribing the drug, the sooner women can at least try it, to see if it will work for them. I started prescribing in October, so expect to hear in December, after the recommended two months, whether it’s been beneficial.

If it works, happier lives. Fuller, happier lives. The medicine will keep getting better. Have hope!

Celebrating the First FDA-Approved Treatment for HSDD

The FDA’s announcement yesterday that they’ve approved flibanserin is huge for women. This is the first medication approved for treatment of hypoactive sexual desire disorder (HSDD), also called female sexual dysfunction (FSD) and, more recently, female sexual interest/arousal disorder (FSIAD—a new abbreviation!).

The multiple names for the condition we’re treating tell a story all by themselves. It’s been a long road to get sexual arousal issues for women the same attention as has been paid to erectile dysfunction in men, perhaps because the symptoms are less visible. The media coverage of the process, I’m hopeful, has had some educational effect, endorsing FSIAD as a real medical condition with real potential for treatments. I have new reason to be optimistic that this decision will lead to further developments in the field—because it’s been proven that it is possible to get a medical treatment in this arena through the FDA approval process.

This approval is great news for women who suffer from this specific medical diagnosis, for whom I, as a menopause care specialist, have had nothing to offer. It’s great news for their partners, who, along with the women, have some hope and optimism that the desire and passion they once shared may be restored to their relationships. I’ve heard from women in my practice about the double-whammy of their loss of desire: Not only do they miss their sexual selves, they regret the unintentional messages they’ve sent their partners.

I’m hopeful that hearing about this development will encourage more women to be frank with their health care providers. At least half of women will have sexual difficulty at some point, but far fewer of them will bring it up to their doctors. If they know there’s a possible treatment, perhaps women will have more motivation to ask. I haven’t seen a study, but I’d be willing to bet that more men asked doctors about erectile dysfunction when they’d heard Viagra was available.

Together with my patients facing the FSIAD diagnosis, I can have a conversation about the potential benefits and side effects of this medication. We can make a plan of action. The women I serve aren’t expecting miracles; any possibility of even a modest improvement will be life-changing for them.

As a doctor, I'll now have something to say after "no, it's not all in your head" and "I'm sorry." I can't wait.

Watching for Herstory to Be Made

Even though I’m a medical doctor, I’m not accustomed to watching the Food and Drug Administration’s actions as closely as I have the past few months. If you’ve followed this blog, you know that last October, I traveled to Washington DC for a public hearing and then a workshop of women’s health experts. The FDA sponsored the events to hear about women’s sexual health and to examine how they might respond.

And then in June, an advisory committee to the FDA recommended the approval of flibanserin, a medical treatment to address hypoactive sexual desire disorder (HSDD). The FDA is poised to announce its decision next week.

It’s been a long road. I first wrote about flibanserin back in 2010, when the company that had developed fibanserin shelved it, saying that it didn’t have sufficient “potential to make it to market.” There’s been controversy about the HSDD diagnosis, although it was first medically characterized in 1977 in the Journal of Sex and Marital Therapy and is listed in the International Classification of Diseases.

More important to me than those scientific listings are specific women I’ve seen in my practice. They’ve had satisfying sex lives. They love their partners. They want to want intimacy. They don’t have psychological problems, relationship issues, social hang-ups, or a medical problem—beyond HSDD. Brain scans show different activity and structure in women with HSDD, proving the biological component.

As their doctor, I want to offer them options to reclaim the life they want, which includes intimacy. It’s up to each woman to decide which of the options she’d like to try, and then to determine whether each option is working for her.

Beyond the approval of this one pharmaceutical product, the FDA’s action is, I hope, a signal for a bright future. When I was there in October, I heard that the agency “recognizes that this [female sexual dysfunction, or FSD] is a condition that can greatly impact the quality of life,” and that “the FDA is committed to supporting the development of drug therapies for FSD.”

As a physician, I’m committed to the least invasive, simplest solution for each woman. But when that simplest solution doesn’t work, I’m deeply grateful for well-tested, thoroughly researched pharmaceutical options that help women restore the fullness of their lives.

July 13, 2015

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arousal ›   intimacy ›  


The Hidden Benefit of "Exercise"

In an ideal world, we’d all love our bodies exactly as they are. We’d love our little muffin tops for the reminder of all the ice cream sundaes we’ve shared with a best friend, our marshmallow tummies for the children we carried, and our pancake boobs for making bras (practically) pointless.

But we don’t live in an ideal world, and the way we perceive our bodies affects how we feel about having sex. We probably all have personal experience with this, and research backs it up.

Fortunately, there’s a way around poor body image and it’s called exercise. Before you groan and stop reading, just let me say that this post is about more than exercise’s effect on that muffin top. It’s about exercise’s effect on a whole lot of things.

Research shows that exercise improves body image, desire, and (our male readers will be happy to know) erectile functioning. It also leads to an increase in overall sexual satisfaction, according to research, the findings of which were published in the Electronic Journal of Human Sexuality.

And here’s the best part of that research: the exercise doesn’t even have to be strenuous. “Overall sexual satisfaction was significantly associated with all modes of exercise/physical activity (i.e., sport, aerobics, recreation, and strength training).”

Improving your satisfaction with your sex life might be as simple as taking a walk or a leisurely bike ride or going canoeing—the more frequently, the better. So the benefit of exercising isn’t just that it tones our bodies. It’s that we feel better about ourselves and our sex lives, maybe long before the effect shows up on our middle-aged middles.

Perhaps you already do those walks or bike rides. If so, good for you! Want better orgasms? Consider adding weights or aerobic exercise to your routine; the research also showed that strength training had “the strongest relationship to overall satisfaction with quality of orgasm.” And many studies show a correlation between aerobic exercise and quality of orgasm.

See? No need to be deterred by the word “exercise.” Just think of it as adding a little more activity that will lead to getting a little more action.

November 17, 2014

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arousal ›   intimacy ›  


Films to Fuel the Fire

When I read the results of a new study showing that couples who watch and then discuss movies about relationships could reduce the likelihood they would divorce, it occurred to me that watching movies that include sex scenes might have a similarly positive effect on one’s sex life.

Friend, it does, and the reason is simple. Sitting down and watching a movie together on any topic—be it global warming, relationships, or sex—creates mindshare for that topic. And when it comes to sex, once you’ve created mindshare, the rest often takes care of itself.

We’ve talked about movies before, and our difficulty in finding them. I’ve been pressed for time the last month or so, so I asked a friend for some recommendations to pass along. She did some research—and a lot of movie-watching—on our behalf and recommends these three movies—movies with real storylines, acting, cinematography, and sex scenes that spring organically from the plot—guaranteed to remind you and your significant other that each of you are not only a spouse, parent, child, employee, or committee chair, but also a lover. (The comments are hers, but she also helpfully included links to New York Times reviews if you’d like confirmation!)

Y Tu Mamá También (NR, subtitles, New York Times review)

Julio and Tenoch, teenage boys in Mexico, can’t believe their luck when Luisa, a (slightly) older woman, agrees on a whim to go on a road trip with them to find a beach. Carnal relations ensue, some more surprising than others, but so does self-awareness. If, at the outset, the movie feels like a Mexican American Pie (the first sex scene occurs 20 seconds in, and the boys have a manifesto that includes “do whatever you feel like” and “don’t marry a virgin”), don’t be discouraged. It gets better. Luisa eventually tires of their immaturity and makes the rules, which the boys agree to follow. Her own manifesto includes “I pick the music,” “You cook,” and “You’re not allowed to contradict me.” Now that’s sexy! And there is a secondary storyline that hints at Mexico’s political and economic landscape seen from the car windows as the threesome cross the country. Sexy, funny, sad, and smart.
Sex and Lucía (NR, subtitles New York Times review)
This movie had me at the premise: Lorenzo is a writer; Lucía is an avid fan. She tracks him down, says she loves him and his novel, and moves in with him that same night. “I always liked people who tell good stories,” she says. “I trust them.” But should she? Lorenzo has a complicated past, and he’s also writing another novel; in the movie, you can’t always tell whether a scene is real or one he’s writing for his novel. No matter. Just enjoy the ride, particularly during the sweet and explicit (yes, both!) photo shoot L&L do together at 28 minutes, and a sexy (Lucía’s) and funny (Lorenzo’s) strip tease a few minutes later. A person might pause the movie there and get down to business with the one you’re with. Later you can resume the film, which gets a good deal darker, and try to untangle fact from fiction over a nice glass of wine.
The Lover (NR, New York Times review)
French Indochina, 1929, is the setting for this story about forbidden love between a French teenager from a dysfunctional family and a wealthy Chinese man who is besotted with her—but betrothed to another. The plot unfolds in a leisurely fashion, giving the story time to build. Looks are exchanged and fingers are tentatively touched, before they give in, but oh, when they do (38 minutes in for about 10 minutes), it’s a beautiful, aesthetically pleasing thing. The lovers are doomed, of course, but until the day of reckoning, they escape their own pain and inflict (primarily emotional) pain on each other. As with Sex and Lucía, to avoid having the plot spoil the mood, pursue your own agenda whenever you’re ready (if not by the 54-minute mark, then certainly after).

In fact, that’s good advice for watching any of these movies. Act now (and now, and ohhh, now); discuss later. According to research, both are good for your relationship.

And we’re always happy to hear from you about movies that stoke your flames!

November 10, 2014

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arousal ›   conditions ›  


The Lowdown on Libido

Once upon a time, you may have felt sexual desire hit with the force of a tsunami—no mistaking the intensity of that jump-your-bones drive. These days, it passes like a gentle drizzle. If it comes at all.

Meanwhile, back at the doctor’s office, one of the most frequent questions this gynecologist hears (and I would agree) is: What happened to my sex drive?

Loss of libido is common. The numbers are all over the map, and I’m not sure that they’re particularly helpful anyway, but many women—and men, too—experience a loss of sexual desire. And this state of affairs can stir up a lot of consternation and unhappiness in the bedroom and beyond.

Lack of sexual desire has a couple of dry, scientific names: hyposexual desire disorder (HSDD) or hypoactive sexual interest and arousal disorder (this one, HSIAD, is relatively new, coined in the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders [DSM]; can you imagine the discussion at the recent FDA forum?). Despite studies exploring its frequency, causes, and symptoms, no pharmaceutical silver bullet has been found to fix it—yet. And, believe me, having tasted the commercial success of erectile dysfunction drugs like Viagra, pharmaceutical companies are extremely keen on finding a similar blockbuster drug for women.

Loss of libido all by itself isn’t the problem—exactly. If you are content to let your sexual self recede with your youth, and this isn’t disturbing to you or anyone else, then by definition you don’t have HSDD/HSIAD.

If, however, loss of libido is distressing to you or to your partner; if you want to continue enjoying sex with your partner and you mourn the loss of your old sexy self, then you have a problem. According to medical diagnostic manuals, in order to meet the criteria for HSDD/HSIAD, you not only have to lack desire for any form of sexual activity, but this also must cause you or your partner “personal distress and/or interpersonal difficulties.”

Loss of sexual desire is a tough nut to crack. There’s no “on” switch for libido; there’s no one-size-fits-all therapy; there’s no FDA-approved drug. So rather than searching for a quick fix for a waning libido, you may have to take a patient, holistic, experimental, long-distance view of the situation. You (and your partner) may have to adjust your expectations: sex can still be close and satisfying, but it may be different.

Additionally, you may have to take a clear-eyed assessment of your overall health and lifestyle because, like so many things, sexual response doesn’t happen in a vacuum. It’s intimately connected with other parts of your physical and psychological health.

With this in mind, loss of libido can be affected by:

  • Loss of hormones—the loss of both estrogen associated with menopause and testosterone associated with aging. Low libido is a frequent complaint of post-menopausal women and those with surgically induced menopause due to removal of ovaries.
  • Some medications, for cancer and depression, for example, are known to depress libido, as are some recreational drugs.
  • Some illnesses, such as diabetes and kidney disease, can disrupt hormone levels and damage nerves in the genital area.
  • Relationship problems. If you have a rocky relationship with your sexual partner, disinterest in sex is a likely side-effect. Stir in some menopausal changes and you have a discouraging environment for sex.
  • Stress and anxiety. Financial worries, career challenges, family problems. It’s hard to feel open to sex with major life issues on the brain.
  • Abuse, whether physical, sexual, or emotional, especially if the abuse is still ongoing.
  • Obesity, which for the women I meet in my practice has most effect on self-image.

We’ve mentioned before that good sex is good for your health. So, how does losing your libido impact health and well-being? A 2009 study conducted by a team of researchers at University of North Carolina at Chapel Hill sought to answer those questions.

In a survey of almost 2000 women, the researchers found that women with HSDD/HSIAD were more likely to be depressed and dissatisfied with their home lives and their partners, and that they were more likely to have other health issues, like heart disease and thyroid problems. In fact, the effect of HSDD/HSIAD on quality of life measures was comparable to that of other chronic health conditions, such as back pain or arthritis.

Ouch.

So what’s to be done with a case of lost libido? How do you begin to tackle this very real and very frustrating condition?

Fortunately, there’s a lot you can do, from lifestyle changes, like exercising and losing weight, to pharmaceutical regimens, which, while limited, might include estrogen replacement or using testosterone off-label. And while you may have to experiment, in the end, you can be every bit as intimate, sexy, and feminine as ever.

I’ll dig into those details in a future post. In the meantime, your recommended reading is my new book, Yes You Can: Dr. Barb’s Recipe for Lifelong Intimacy. Because that’s what we’re all about here—believing that we can.

March 13, 2014

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arousal ›   women's sexual health ›  


Q: Can I regain my desire?

I wish there were a "secret sauce" that worked for all of us to restore libido. Not surprisingly, it's more complicated than that.

It's somewhat unusual to have an abrupt change to libido; for most women, it's a "slow drift." The first thing to consider with a dramatic change is any new or different medications. There are quite a few that have effects on desire: blood pressure, pain, and mood medications (antidepressants) to name a few. If you have had a change, you can work with your doctor to experiment with dosage or medications; let him or her know of this unintended side effect.

You ask about Cialis and similar products. They can help with orgasm (as they do for men), by arousing blood supply to the genitals, but they don't have an effect on libido or desire.

One option to consider is testosterone. While it's thought of as a male hormone, it's also present in women and is linked to libido. Some physicians aren't willing to prescribe it for women because it's an "off-label" use, but 60 percent of women report significant improvement in libido with testosterone replacement, and 20 percent of U.S. prescriptions for testosterone are now for women.

The other factor important to consider is mindfulness--which we might also call intentionality. While you may not feel desire that motivates you to be sexual right now, you know your long-time partner does. You can make the decision (together) that you will continue this activity together, including foreplay. (And I note a recent study that linked frequency of sexual activity with the quality of relationships, which confirmed my intuition.) When you make that decision, sex is a "mindful" activity: You anticipate and plan it and prepare physically and emotionally for an optimal experience with your partner.

Many women grieve the loss of a part of their lives that was once so important and fulfilling. It's most often an unnecessary loss, and staying sexually active has many health benefits as well as giving us feelings of both individual wholeness and connection to our partners.