December 09, 2014

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Condition News ›   HIV ›   safe sex ›   STDs ›   STIs ›  


Single? Sexual? Be safe

Recently, a friend and her sister visited a retirement community in our neighborhood. They chatted up several residents, including the sweet, 90-year-old widower who’d lost his beloved wife some months before. When they turned to leave, he asked the sister for her phone number. Since she is 50 and married, they laughed it off. Not long after, they heard that their elderly Don Juan had found himself a girlfriend in a nearby senior living community and was visiting her regularly.

The anecdote is cute, but it also points to a larger reality. We are never too old to enjoy sex—that’s the entire premise of this website—but somewhere on the road to the golden years, single seniors have thrown youthful caution to the winds when it comes to safe sex. The result is that sexually transmitted infections (STIs), such as Chlamydia and syphilis, are spreading more quickly among people over 55 than among any other age group except 20-24 year olds, according to a 2010 report from the Center for Disease Control and Prevention (CDC).

Even more alarming—one in four people with HIV/AIDS is over 50. In the Sunbelt, where large communities of seniors live, the rates of increase are off the charts: In two counties in Arizona cases of syphilis and Chlamydia among those over 55 rose 87 percent between 2005 and 2009; in central Florida, the increase was 71 percent, according to this article in Psychology Today. News reports use words like “epidemic” and “skyrocketing” to describe these increases. Medicare has begun offering free testing for STIs, but most (95 percent) of seniors remain unscreened.

What the heck is going on here? What happened to all those lectures in responsibility and self-control we subjected our kids to? What seems to be happening is that we are, luckily, more long-lived and healthier than our forebears. We are also newly empowered with drugs to maintain erections for men and to make sex more comfortable and enjoyable for women. All the years of hard work, career-building, and childrearing are in the rearview mirror. Many of us find ourselves alone and treading tentatively back into this brave, new world of sex and dating. Add to this the sometimes freewheeling life in retirement communities (some of which are the size of small cities), which create hotbeds (no pun intended) of people of similar age and background—kind of like a college dorm.

Trouble is, unlike kids in a dorm, seniors don’t have to worry about pregnancy and aren’t nearly as well-informed about the risks of unprotected sex. Condom use for those over 60 is the lowest for any age group (6 percent vs. 40 percent for college-age males). And condoms, in case you’ve forgotten, provide the only dependable protection against STIs, and even they aren’t effective against every sexually transmitted bug.

Also unlike their much younger counterparts, older folks have a less robust immune system, so the chances of catching and spreading infections are higher. Plus, many STIs are asymptomatic, so the person doesn’t know he or she is infected—and that the STI is degrading the immune system even further. Finally, doctors rarely think to ask Grandpa about his sex life in the normal course of an exam, even if he has classic symptoms of an STI.

All this adds up to a lively Petri dish of bugs circulating around the singles scene. Yet, prevention is so easy, and the cost of ignorance or of ignoring common-sense precautions is high. So, ladies, even if the prospective partner is someone you’ve known all your life, don’t assume you’re familiar with the intimate details of his sexual forays. Others have walked this path before—and are paying the price. Jane Fowler, 71, and founder of HIV Wisdom for Older Women, was infected with HIV by just such a friend when she was 55 and now advocates for more information and support for older women with AIDS. I’d suggest that if you’re dating, stick a couple condoms in your purse right with the lipstick. And get yourself tested if you’ve ever had unprotected sex. And read this series of posts about STIs on MiddlesexMD. The rule of thumb these days—better safe than sorry.

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.

A Sexy Toolkit for Breast Cancer Survivors

Recovery from a devastating disease like breast cancer is a long and challenging road that frequently involves making peace with lots of change—different bodily sensations, altered abilities, different goals and perspectives. Rather than a return to “business as usual,” recovery is often a process of accommodation.

All that adaptation and accommodation applies to sex as well. Sometimes, the goal is not so much to regain the “before” experience as to redefine, along with your partner, what sex means “after” cancer. To start from now with patience and hope, because whatever your starting point, you will improve. That’s the resounding message from other survivors who have faced the same journey: “Don’t give up,” and “You are not alone.”

As you reconstruct the contours of your life, of which sex is a critical part, here’s a toolkit that might help you get started and might also help sex to be more comfortable.

First, some ideas to consider as you begin to reclaim your sexuality:

Self-image is a huge hurdle for most women who’ve had breast cancer, even after reconstruction surgery. Everything feels different, and sometimes there’s no feeling at all. According to a 2011 study of 1,000 survivors of breast cancer, co-author Mary Panjari, of Australia’s Monash University, found that women with body-image issues (and who doesn’t have issues with body image?) were much more likely to report sexual function problems.

Perhaps it’s comforting to know that, while you struggle with the psychological and physical scars of your illness, for most partners, the way you look isn’t a problem. “In our study, we asked women if they thought their partner felt differently about their appearance and the majority said, ‘No different.’ But the women felt differently about themselves,” says Panjari. Again, you're not alone, and there are steps you can take:

  • Consider finding a support group for cancer survivors, and not just for advice on sex. Some women like them; others don’t, but at least give it a try.
  • Consider couples therapy. As a couple, you need to figure out a path forward, sexually speaking. He may worry about hurting you or pressuring you. You may be consumed by how you look or experiencing loss of desire and sensitivity, vaginal dryness, numbness. And your medications may exacerbate your condition. Finding a sex therapist who can walk you through these changes could be your best gift to yourself and your relationship.
  • Exercise when you feel ready. A regular workout will help you tone muscles, lose weight, and feel stronger and more capable. It gets more blood to your brain and your bottom, and it releases endorphins, the feel-good neurotransmitters in your brain. Simply feeling confident and capable can help stimulate your sex drive.
  • Masturbate. This primes the pump. You can get lubrication going and see what feels good where. “Masturbation is a normal form of sexual activity and release,” says Dr. Marisa Weiss, founder of Breastcancer.org. “I tell my patients it's a form of exercise and conditioning for the vagina—which has suffered considerable change and lack of use during breast cancer treatment.”
  • Remember: Breasts are only one part of a whole-body experience. Don’t focus on the tree when you have an entire forest to explore.
Now for that toolkit. These are items every postmenopausal woman should have on hand—they’re just more important for breast cancer survivors.
  • Vaginal moisturizer. This is for regular, daily use, not just for sex. It conditions the vagina and keeps the tissue healthy and moist
  • Lubricant. Use this lavishly in your vagina for extra lubrication during sex.
  • Pillows. Lots of pillows for soft support where you need it. If a position feels ouchy, try cushioning the area with a pillow.
  • Erotic movies and other scene-setting paraphernalia—candles, incense, music.
  • Sexy attire. If you need to start out—or stay—clothed for a while, get sexy lingerie that covers the strategic parts.
  • Read the information about vaginal comfort and genital sensation on my website: middlesexmd.com and the very helpful blog posts about sex after cancer by our own medical advisor, Mary Jo Rapini.
   

Lifestyle Choices for Breast Health

You know that silly song about the thigh bone being connected to the hip bone—and so on?

Well, the kernel of truth in the ditty is that, when it comes to health and our bodies, things are indeed beautifully and intricately connected.

You can’t do healthy things for your thigh bone—or your heart or your sex life—and not have it affect other corporal systems as well. So, while we might focus on breast health in honor of Breast Cancer Awareness Month, rest assured that healthy, cancer-free breasts involve habits and choices that are good for the rest of your body as well.

There’s a lot to celebrate when it comes to breast cancer, like steadily decreasing rates since the year 2000. But we still have a long way to go. About 12 percent—1 in 8 women in the US—will develop invasive breast cancer sometime in her life. Our most significant risk factors are 1. being a woman and 2. being older.

Women over 55 account for two-thirds of invasive breast cancers diagnosed each year. This is because, over time, we tend to accrue genetic mutations, and with age we’re less adept at repairing them.

Those are the facts. But we don’t have to helplessly wait for the shoe to drop. We can make lifestyle adjustments that will lower our risk of getting this cancer and improve our overall quality of life, including our sex life. (And don’t forget that a healthy sex life is also good for our health.)

Because it’s all connected, right?

So here are lifestyle changes that you can make specifically targeted toward breast health:

Maintain a healthy weight. Being overweight or obese—those with a body mass index (BMI) over 25—increases one’s risk of developing breast cancer, especially in postmenopausal women. This could be because estrogen is stored in fatty tissue, and women who have more fat are also exposed to higher levels of estrogen, which has been undeniably linked to breast cancer. But other issues related to obesity may also be involved, such as insulin and glucose levels. Some estimates suggest that 17 percent of breast cancers in North America could be avoided simply by maintaining a healthy body weight. Check out this page for a solid, common-sense approach to weight loss.

Eat healthy food. Not only will a healthy diet help maintain a healthy weight, but it’s a critical component to avoiding cancer. Some foods contain properties that help repair the wear and tear to our bodies in the normal course of life. These “super foods” contain antioxidants that help protect our bodies from cancers.

The link between food and cancer isn’t always straightforward or well-understood, and dietary fads change with the season. Basically, though, the approach to healthy eating remains the same: eat a variety of foods with an emphasis on fruits, vegetables, and whole grains. Avoid processed foods. Avoid fats and sugars. Above all, avoid super-sugary beverages, which are directly linked not only with obesity but also with some forms of cancer.

Finally, eat fresh and eat at home. (You can’t control what goes into your food at a restaurant.) Eat organic foods to avoid exposure to synthetic chemicals.

While the voices touting various diets and food fads are myriad, confusing and contradictory, here are some basic food facts from breastcancer.org. The USDA also has a website with tons of food and diet information here.

Exercise. Weight, diet, and exercise. This is the trifecta of good health. Some well-regarded sources say that 30-40 percent of cancers could be avoided simply with these healthy lifestyle choices. That’s staggering. And when you add in quality of life factors that come with the trifecta, well, it’s overwhelmingly worth the difficulty of losing weight, eating well, and exercising regularly, wouldn’t you say?

Regular, moderate exercise can lower your risk of breast cancer. Not to mention all the other good things you get with exercise, such as better mood, cardiovascular and joint health, greater stamina and flexibility, better sleep, better bones, and more regular bowel movements. What are we waiting for?

Even women who have already been diagnosed with breast cancer may improve survival rates or prevent recurrence with moderate exercise, like walking only 4-5 hours per week, according to the American Cancer Institute.

Don’t have time? As the trainers in my exercise video say, “Make time.” It doesn’t matter what your physical ability is right now—just start slow and keep on going.

Don’t drink. Sorry to be a killjoy, but the more you drink, the greater your risk. A woman who has three alcoholic drinks per week is 15 percent more likely to get breast cancer than a woman who doesn’t drink at all. If you’re on hormone replacement therapy or if you’ve already been diagnosed with breast cancer, you should be one of those non-drinking women.

What about that healthy glass of red wine? Sorry, it all counts. The benefit of red wine doesn’t outweigh the risk. If you’ve never had breast cancer, just don’t drink every day, but if you have risk factors, switch to non-alcoholic options.

Don’t smoke. This almost goes without saying. Yes, the major risk is lung cancer, but actively smoking as well as exposure to second-hand smoke increases the risk of breast cancer in premenopausal smokers. Plus, women who smoke have greater difficulty recovering from breast cancer treatment.

Avoid chemical exposure. This is like trying to dodge raindrops, given the chemical soup we live in every day. And most of the chemicals in our environment and in the things we use have never been tested for toxicity or carcinogenic properties. Some types of chemicals are known to be hormone-disrupting, which alter the way our natural hormones function. Research is ongoing about the way these substances work and their link to possible cancers, but the connection isn’t well understood.

In the meantime, how do we negotiate the reality of the world we inhabit without neurotic overreaction but also without putting our heads in the sand? Of greatest concern with regard to breast cancer are those chemical with hormone-disrupting properties, including those in pesticides, growth hormone residues in meat and dairy products, and certain plastics.

In general, some precautionary practices would be to

  • Buy organic food. Here’s a list of the “dirty dozen”—the foods that have the highest levels of pesticide residue.
  • Plant a garden. Put up your own food.
  • Use fewer and simpler cleaning and personal care products. Look for certified “green” cleaning products (with GREENGUARD or EcoLogo insignias, for example) or make your own.
  • Don’t use pesticides on your lawn or garden.
  • Use BPA-free plastics or glass or stainless steel jars and bottles. Avoid #3 (PVC), #6 (polystyrene) and #7 (polycarbonate) plastics, which are linked to breast cancer.
You may not be able to tackle everything on this admittedly intimidating list, but it’s better to make a few changes than not to do anything at all. And the foundation you lay now will become even more important in maintaining health and functionality as you age.

Think about What #WomenDeserve

This summer, in a blog post on the absence of pharmaceutical options for my treatment of women with hypoactive sexual desire disorder (HSDD), I said “I’m not in the room for the FDA discussions.” Thankfully, that’s about to change.

I’ve written here a number of times (as early as 2010 and as late as earlier this year) about the progress with the pursuit of “pink Viagra” and its frustrating setbacks. My message has consistently been that women’s sexuality is complicated, and no pill is going to fix everything for everyone.

But because of that very complication, as a physician, I value having options available. For one woman, simply thinking about intention and follow-through is enough to change the equation. For another, a combination of moisturizer, lubricant, and a powerful-enough vibrator is restorative. A third may require localized estrogen to rejuvenate tissues and restore comfort. You get the idea.

What that means is that the more options I have, the more likely I am to be able to work with a woman to maintain or restore the level of physical intimacy and sexual activity she wants. And I’m increasingly aware that while there are 26 drugs approved by the FDA for men’s erectile dysfunction, there is nothing that’s been approved for women facing comparable issues.

It’s not for want of trying. From the outside, it looks as though the bar is set higher for drugs for women than drugs for men. The side effects noted for drugs recently considered seemed more mild than that list we can all recite from hearing Viagra commercials since 1998. It doesn’t matter whether this is an intentional bias; what matters is that the FDA assure that it’s even-handed and supportive of women and their sexual health moving forward.

And that’s where the change comes in. Later this month, I’ll be traveling to Washington, DC, to attend a public hearing and then a workshop of women’s health experts, both intended to establish the reality of women’s experience (43 percent of us suffer from some sexual dysfunction!) and how the FDA can productively respond.

You can lend your voice to the proceedings. There’s a consortium of us who are concerned with women’s sexual health. We’re gathering signatures to a petition so that it’s clear to the FDA when we meet that this is a real problem, suffered by real women who seek a range of solutions. Add your voice at EvenTheScore.org or sign the #WomenDeserve petition at Change.org. Follow the discussion at the WomenDeserve Facebook community.

And I’ll keep you posted on the progress your voice has supported!

September 22, 2014

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back pain ›   Condition News ›   sexual intimacy ›  


Common-Sense Tips to Ease Back Pain during Sex

Whether you have a little twinge or serious back pain during sex (and who doesn’t now and then?), these preventive measures can help ease the pain.

Explain the problem. Don’t leave your partner in the dark. Chances are, if you seem unwilling to have sex, your partner may interpret that as rejection. That’s almost as painful as back pain.

It’s hard to admit to physical limitations, especially in the sexual arena, but this is one of those topics that need airing. Then, it’s possible for your partner at least to understand the issue and more likely to become an ally in the search for solutions.

Medicate. Take an ibuprofen-type medication before sex. Or discuss using another pain-killer with your doctor.

Prepare. If your muscles tend to spasm, a hot shower before sex and cold compresses after could help. Or work a little massage with painkilling cream into your foreplay.

Innovate, don’t stress. Take your time. At this stage of the game, sex is more about connection than athletics. It’s more about enjoying the moment than setting off fireworks. Depending on the type of pain, try positions that support your back and reduce spinal movement. Experiment with support pillows to see what keeps you both comfortable. Or switch to other types of pleasuring if things get too gnarly.

September 18, 2014

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back pain ›   Condition News ›   sexual intimacy ›  


New Research Addresses Pain-in-the-Back Sex

Connect the dots for me here:
  • Research consistently ranks good sex as an important component of quality of life.
  • Back pain is a serious deal-breaker to good sex because when your back hurts, sex does too.
  • About 31 million people suffer from low-back pain in the US, according to the American Chiropractic Association.
  • From 34 to 84 percent of those people have sex less frequently, depending on what study you read.

Ergo, if you suffer from back pain—and a whole lot of people do—you’re probably having sex less and enjoying it less, as well.

That’s a lot of lost quality of life.

Now, for the first time, a group of researchers from the University of Waterloo in Canada actually studied how the back moves during sex, adding some hard data to support, and in some cases, debunk, the common advice doctors give their patients.

The first phase of this research focused on how the spine moves in a normal, healthy male during sex. To do this, lead researchers, Natalie Sidorkewicz, MSc, and Stuart McGill, M. PhD, recruited 10 heterosexual couples who did not have back pain.

Then they wired them with reflective sensors and told them to “move as naturally as possible” in five different sexual positions: two versions of the missionary position, two versions of the “doggy-style” position, and “spooning” or side-lying (the most common position recommended for people with back pain).

The researchers analyzed the data and identified the positions that were most “spine-sparing”—involving less movement—for different types of back pain.

Some people—and this is more common with age—experience back pain when they sit or bend forward. This is “flexion-intolerant” back pain. The best position for the flexion-intolerant is the quadruped or a missionary position with the male on his hands.

A second type of back pain is called “extension-intolerant,” which means that lying on the back or stomach is painful. For this type of back pain, spooning may be a better position.

For some people, any movement causes back pain, and for these “motion-intolerant” types, sex remains challenging. In general, however, movement (and pain) is lessened when it is shifted to the hip and knee, as in the quadruped position when the female is on her elbows.

With any of these positions, small adjustments—whether a person is on elbows or hands, for example—significantly changes the amount of back movement involved.

The best option for the person not controlling the movement (the females in this study) is to keep the spine in a neutral position, by supporting the small of the back with a pillow in the missionary position, for example.

A chart illustrating the best position for different types of pain is here.

Future research will focus on female back movement during sex and how the spine is affected by orgasm. The researchers also want to study the effect of various positions for actual back pain sufferers.

All this is the beginning of good news for people with back pain. Previously, medical recommendations have relied on “conjecture, clinical experience, or popular media resources,” according to the University of Waterloo study. Hard data is a welcome addition.

Researchers also hope their work will spark more dialog between patients and health care providers about sex, now that practitioners have real research to refer to in discussion with patients with back pain.

Stuck without Solutions

If you’re a regular reader of the MiddlesexMD blog, you might think I’m a broken record on the topic of the dearth of pharmaceutical tools to address hypoactive sexual desire disorder (HSDD). That’s because I am. I don’t know how else to respond to where we are, except to keep talking about it, to make sure we’re all sufficiently aware—so we can all be clear, when the subject arises, about what we want and need.

As I encourage us all to recognize, women’s sexuality is complicated from the start, and becomes more so as we enter perimenopause and menopause. Our sexuality is an intermixing of the physical, psychological, and emotional. It often takes some experimentation for women to get back on sexual track, sometimes because it’s not clear whether a physical problem is in the lead or it’s really stress or a relationship issue that’s diminished desire.

In that experimentation, I prefer, as a physician, to start with the simplest steps first. That may mean adding a lubricant or a vibrator to a woman’s bedside table; it may mean using dilators for a time. But also as a physician, I appreciate knowing that there are pharmaceutical options in my repertoire, too, to help a woman get unstuck.

So I follow the news about drugs in development, and about their progress in getting approved for use by the FDA. Earlier this summer, I received an update from the Board of Directors of the International Society for the Study of Women’s Sexual Health (ISSWSH). They wanted to be sure that we’d seen an ABC News story on Flibanserin, which is still stalled out on appeal, subject to additional study.

“No single drug will ever be a cure-all in sexual or most other conditions, let alone effective for 100% of appropriate patients,” the ISSWSH statement read. “But that is never the standard by which biopsychosocial drugs are approved.” The news story also questions whether the standards for drugs for women’s sexuality are different from those for men. It compared side effects of dizziness, sleepiness, and anxiety to those listed in “iconic Viagra commercials, such as nausea, diarrhea, and the risk of erections lasting over four hours.” The reporter suggests that the bar seems higher for drugs for women.

I’m not in the room for the FDA discussions, so I don’t pretend to know whether there’s bias at play. I simply point out that there are 25 FDA-approved medications for men’s sexual dysfunction, and none that address HSDD for women. None. As a physician, I’m conscious of that void whenever I’m talking to a patient who misses her sexual self.

What do we do? Keep talking about it, even if we sound like broken records. And, if you haven’t already, you can sign on to the ISSWSH Wish Petition. The number of names listed does help to communicate the importance of this issue to women and the men who love them—as well as to the health care providers who serve them!

Women Suffer from Erectile Dysfunction, Too

We received this submission from UK-based kindred spirits, looking to maintain intimacy for women--and their partners--just as long as they choose.

Erectile dysfunction affects millions of men in the UK and there is often embarrassment surrounding the issue. Erectile dysfunction is when a man cannot get or maintain an erection which makes engagement in intercourse impossible. In fact, the NHS estimate that 50 percent of men aged between 40 and 70 will suffer from erectile dysfunction at least once in their life.

The main causes of erectile dysfunction are both psychological and physical. Sometimes hormones can be the problem, as can high blood pressure and high cholesterol which cause the blood vessels to narrow and sometimes erectile dysfunction can occur as a result of surgery or an injury. Not only can erectile dysfunction be a symptom of other health problems, it can also be the cause of psychological effects. Erectile dysfunction can have a serious effect on a man's mental well-being, because it can damage his self-esteem. However, the relationship between erectile dysfunction and psychological issue can be seen as a vicious circle; not only can erectile dysfunction be the cause for reduced self-esteem and depression, but anxiety and depression are also listed as common causes of erectile dysfunction.

It's not just men who are psychologically affected by erectile dysfunction, either. Women can get emotionally hurt when their partner is unable to get an erection or maintain one, because they blame themselves and think they could be doing something differently to help their partner. Sometimes women feel rejected when their partner suffers from erectile dysfunction, assuming that their partner can't get an erection because they are not adequately aroused.

Of course this does not help make the situation any less stressful for the male suffering from erectile dysfunction and the situation is often made worse. Relationship problems can often occur as a result, because tense situations arise and couples are too embarrassed to talk about the issue.

According to clinical psychologist Mark L. Held, PhD, the best thing to do is talk about erectile dysfunction before it becomes a strain on the relationship. Held says discussing the issue is crucial because:

“Almost all men have erectile dysfunction at some point... it’s how they deal with it that counts.”

Sex therapy can be an effective solution for couples whose relationship is suffering as a result of erectile dysfunction. A qualified therapist can help couples talk through the issues that have arisen, as well as help them identify and work through the psychological reasons that are causing it in the first place.

There is a plethora of medications that can help against erectile dysfunction. Perhaps the most famous one is Viagra, but there are now many more that work better for different patients. In any case, sufferers should discuss the issue with their doctors to determine if and which medication is appropriate for their case.

For some help in responding when ED's been countered, see our blog post, "He's Got His Groove Back. O Happy Day?"

Q: No-estrogen options for symptoms of surgery-induced menopause?

You describe hot flashes and night sweats that began after a hysterectomy to reduce breast cancer risk. You're right that the symptoms can be prompted by your sudden entry into menopause (through surgery) as well as by the prescriptions intended to deplete estrogen in your system. You are, as you know, not alone in facing this challenge!

I always start with lifestyle factors, which can lessen symptoms for anyone. You may be able to identify triggers (like caffeine, alcohol, spicy foods, or sugar) that you can avoid in your diet. Dressing in layers is a must for many of us. Now is the time to exercise regularly; women who do so may have fewer and/or less intense hot flashes.

Reducing stress—or learning new tactics to manage it—is helpful if you can do it (I know life doesn't always cooperate). Paced respiration is a technique to ease the intensity of a hot flash when one occurs: Breathe deeply and slowly, inhaling through your nose and exhaling slowly through your nose or mouth. There's also a biofeedback technique to slow the heart rate, which may lessen the hot flash intensity and duration (because an elevation of heart rate is part of the physiology of a hot flash).

Acupuncture has been very helpful to a number of my breast cancer patients in managing hot flashes.

Beyond that, we haven't seen a lot of success with alternative medications and complementary therapies. Those that have been tried include isoflavones (found in soy but not recommended for breast cancer patients), black cohosh, chaste tree berry, ginseng, dong quay, red clover, yarrow and others. For those that have been investigated and undergone careful scrutiny, the results are disappointing; there is limited scientific evidence for most herbal options. That being said, placebo has at least a 25 to 40 percent response rate in nearly every study, so if you can determine that an herb is not harmful (check with your physician) I do not discourage women from trying herbal preparations. I wish we could make a recommendation knowing we are in fact offering beneficial outcomes, but that just hasn’t been so for these options.

There are some non-hormone prescription options that have favorable effects. Just in the past year the FDA approved Brisdelle specifically for the treatment of hot flashes. It cannot be used with Tamoxifen, but as a very, very low dose of paroxitene (generic for Paxil), Brisdelle is well tolerated with minimal side effects. The anti-hypertensive medication clonidine has been shown to reduce hot flashes for some women, as well as gabapentin (generic for Neurontin). Other antidepressants can reduce hot flashes as well: venlafaxine (generic for Effexor), paroxetine, and fluoxitene (generic for Prozac), and escitalopram (generic for Lexapro). All of these have a modest benefit to hot flashes. They each have the potential of side effects, so a discussion with your provider is helpful in determining an option best suited for you.

Good luck, and the good news is that time will work to your advantage for the hot flashes. This too shall pass—really!