Q: My libido is higher than ever! Will it last? Should I be concerned?

When you're in perimenopause, we say that your hormone levels are, in general, declining. While they are declining "in general," it's likely that your levels of estrogen and progesterone are fluctuating erratically from day to day. Testosterone is usually more steady, not particularly fluctuating day to day or month to month. As a result, the mix of hormones changes, and for some women testosterone seems to play a more dominant role; one effect of testosterone is enhanced libido (it's sometimes considered as part of therapy to restore sexual function).

This may explain what you are experiencing. You asked whether you should be tested for hormone levels. While it's possible to measure hormone levels, and those measurements are accurate, the levels are accurate only for that hour or day and are not particularly helpful to predict what to plan on in the upcoming days or months.

I would say, enjoy the current state! I hope this is your ‘new norm.’

Q: Any suggestions for overcoming lack of desire and pain during sex?

The first thing I try to do with women who have both of these issues is to make sex comfortable. It is pretty hard to be interested in intercourse when you know it is going to lead to pain.

You might consider vaginal estrogen--estrogen that is 'localized' rather than 'systemic' and is delivered only to the vagina. This would require a prescription product. Or you need to commit to using a vaginal moisturizer consistently; this reintroduces moisture to the vagina on an ongoing basis.

Once sex is comfortable, then approach the issue of desire, which admittedly, is difficult. Yours might be a situation in which to consider using testosterone or buproprion, an antidepressant that can have the side effect of increasing desire. Engaging mindfulness and choosing sex is important to the sexual relationship. I review Basson’s research with patients, and remind them that desire does not play as big a role in women’s sexuality at this stage of life, so being intentional and choosing to engage is often necessary.

Find a provider you trust to talk through some of these issues and begin to explore options.

Q: Am I stuck with an unfulfilling sex life?

No!  It’s great that you recognize the value of remaining sexually active, despite your decreasing libido.

As we get older, we have to learn some new techniques to continue to enjoy sex. You can use the MiddlesexMD website to have a discussion with your husband:  Take him to the site.  It will help him understand what you're experiencing, and that it's not "about him."  Review together the bonding behaviors and alternatives to intercourse.

You may find a role for erotica, like DVDs or books. Just this week a woman told me that she keeps a book of erotica nearby. It works really well for her to read from it in anticipation of sex (although her husband isn’t aware she has it for this purpose).

If you're comfortable with the idea, incorporating a vibrator may help; after menopause we do require more stimulation for arousal and orgasm. Healthy relationships require intimacy -- it's worth the effort.

Q: Is there an alternative to Zoloft that won’t decrease libido?

Zoloft is an SSRI (selective serotonin reuptake inhibitor), which increases serotonin. That improves mood, but more serotonin is not good for women sexually. Sometimes changing meds within that same class can have different side effects.

Wellbutrin (buproprion) is an antidepressant that increases dopamine. That can have the effect of improving libido, so sometimes adding it is helpful. In this situation, it might also be helpful to measure free testosterone and consider adding testosterone if it’s low.

If you consult with your physician and can't change your anti-depressant, you'll find some other ways to help with libido on our website.

Seeking Worthy Erotica

As a general rule, women over 40 need more stimulation to become aroused enough for good sex. When we were young, just thinking about making love with our partners may have been enough to arouse us physically, but as we grow older, as sex hormones decrease and distractions build, it takes more. But not too much more. For some of us, reading a steamy novel will do it. For others, visual stimulation works better. A hot movie, for instance.

Ever since I first conceived of MiddlesexMD, one of my goals has been to gather a tasteful collection of erotica, visual and verbal art that will stimulate arousal in older women. All we had to do is find it, right? How hard could that be?

None of us at MiddlesexMD had really explored the world of erotic art. So we set our product buyer to work, buying up a sampling of the “state of the art,” beginning with films. She studied and chose a good selection, from how-to films to soft-boiled, story-centered erotic movies. We chose films targeted at women. And films targeted at older women. As the DVDs piled up in our product room, we decided to take an analytical approach to our selection.

Sort of analytical. We each invited a few girlfriends over for glass of wine, a viewing and a discussion.

Our goal was to review these films to gather criteria and characteristics of films that most appealed to our friends — some way to inform our buying choices for the store.  Which would they use? Which would they recommend to their friends or watch with their partners? How would they rate them? What, specifically did they like about each? We had our notepads and our pens poised. We had poured the wine, curled up in front of the TV…

And then, showtime!

One film after another… fell flat on its face. We couldn’t watch more than a minute or two of any of them without reaching for the eject button. There was no analysis, no rating, no pulling apart criteria. We all… hated everything about all of them.

And we were disappointed. Really? Does it all really have to be so awful? We began again, discussing scenes in mainstream movies that we love, that work for us.  We could easily name dozens of scenes that made us blush just recalling them. Scenes from the English Patient, Room with a View, Breathless, Nine and a Half Weeks, Body Heat, The Piano, Atonement, Shakespeare in Love, The Unbearable Lightness of Being, Looking for Mr. Goodbar, The Godfather, Sweetland, The Graduate, Under the Tuscan Sun, Thief of Hearts, Vicky Christina Barcelona, Moonstruck, anything with Daniel Craig in it. We exausted ourselves thinking of the scenes.

And what characteristics did these movies and scenes have that mattered to us? The story is important, the emotions feel real. There is a buildup of passion, tension, and release. The woman’s seduction receives detailed attention. In short, there is romance.

What we didn’t like? Explicit sex. Mechanics. We really enjoy using our imaginations to fill in, and are perfectly happy with closeups of rapt faces.

We learned a lot from each other that night. We learned, too, that among our friends, at least, we’d all rather read a good sex scene than watch one. So now we’re looking for really good erotica to offer in our store.

How about you? Have you found tried-and-true erotica that works for you? What do you like about it? Have you failed to find anything? What is it about the works you’ve tried that doesn’t work for you?

Why We Love Rosemary

Rosemary Basson's model of female sexual response

The science of human sexuality is young. For most of the last century, we assumed that men and women approach sex in roughly the same way.

I know: Crazy. But as I said, the science is young.

Older models (Masters & Johnson, Kaplan) theorized that sex for people happens in a few neat, linear stages, beginning with  desire, proceeding next to arousal, then orgasm, and finally satisfaction.

But it doesn’t always work that way, particularly for women, and especially for women over 40.

More recent researchers who focus on women’s sexuality, confirm that really, women do not experience sex in this simple, linear way. We sometimes skip phases. Our reasons to have sex are many and often complex.

We can be perfectly satisfied with sex that does not include orgasm, and we can reach orgasm without desire. We are flexible that way.

Enter Rosemary Basson, MB, FRCP, of the University of British Columbia. Basson formalized a new model of female sexuality that is now widely accepted.

She offers two key insights. First: Female sexual desire is generally more responsive than spontaneous. That is, we are more likely to respond to sexual stimuli — thoughts, sights, smells, and sounds — than we are to spark an interest in sex out of thin air (Men, on the other hand, specialize in this).

Another key insight: emotional intimacy matters to women. I know, that doesn’t sound like a news flash, but in the realm of the biological sciences, it’s news, trust me.

So Basson drew a new model – not a linear series of steps, but a circle that includes both sexual stimuli — the thoughts that trigger a woman to take an interest in sex, and emotional intimacy — the emotional payoffs of the experience that lead her to want to come back for more.

I love Basson’s model and use it every day in my practice to help my patients understand how sex really works for us.

We need to understand that it’s okay and it’s normal that we don’t always start with desire.  And as we enter menopause, and our hormone levels drop, spontaneous thoughts about sex, and responsiveness to opportunities for sex diminish for most of us. That’s natural and normal too.

If you don’t like the situation, and you want to feel more sexual, more responsive, Basson’s model gives us the hint: We need to stimulate our minds. The more sexual stimuli we receive, the more sexual we feel.

So, this is worth thinking about today, a worthy discussion to have with your partner: What makes you feel sexy? A juicy romance novel? A James Bond movie? Erotic art? Pretty underpinnings? A romantic dinner?  Having your partner empty the dishwasher?  Spend some time thinking about that. Maybe make a list. And then provide for these things. Sexy is as sexy does, friends.

And, hey, if you’d like to help a sister find some sexual motivation, use the comment field below to share. What sights, sounds, scents, scenes help you get in the mood?

Here's more:

Theories of Female Sexual Response

Sex:Desire, Chicken:Egg

Why Women Have Sex