Q: What do you advise for my wife, who’s not interested in sex?

I’m afraid this is a complicated issue. A dozen different contributing factors are possible, and the challenge you and your wife face may be a combination of them. You’re not alone, which is, I recognize, both bad news and good news.

I’ve addressed low libido and many of the contributing factors in blog posts before. Here’s the introduction to the topic on our website; here’s a blog post with additional explanation. Here is a list of answers to specific questions readers have submitted, including certain health conditions or medications which can inhibit libido as a side effect.

You asked. Dr. Barb answered.You didn’t describe your wife’s overall health; I hope she’s had a recent evaluation from her health care provider and has mentioned her loss of interest in intimacy. He or she can help to determine the cause, which will then point to the best options for treatment. You may also find a couples therapist or a sex therapist to be helpful, since emotional as well as physical factors come into play in intimacy.

I do wish you the best with finding the cause and some ways to address it! Physical intimacy adds meaningful dimensions to our relationships.  



December 29, 2016


gratitude ›   health care ›   menopause ›  

So Grateful for You!

This is my quiet moment—the pause between the years, the time of taking-stock. One thing I know for sure—I have a lot to be grateful for this year!

Here's to good health and good sex.It’s been more than ten years already since I decided to specialize in the sexual needs of women in midlife—women like you and me. As I mention here, I wanted to provide clinically sound, research-driven information to women who are caught in the throes of the menopausal transition. I wanted to address our sexual issues head-on, without embarrassment or beating around the bush. I also wanted to provide a safe, tasteful environment in which you could actually buy the products I was recommending—vibrators, lubricants, moisturizers, dilators, vaginal weights.

That was the rationale behind MiddlesexMD. I envisioned a space in which to communicate with a lot more of you than I could see in my clinical practice. A place where you can ask questions or start a conversation and where I can discuss whatever’s on my mind—from research on new drugs and therapies to tips on maintaining sexual intimacy. And we did put together a shop, where you can find those safe, tested, high-quality products, and have them mailed to you in discreet packaging.

It’s been a journey, that’s for sure—rewarding, challenging, busy, and sometimes unexpected. In 2013, the North American Menopause Society awarded me the “Certified Menopause Practitioner of the Year.” Late last year, I published my book, Yes, You Can: Dr. Barb’s Recipe for Lifelong Intimacy. The book uses my recipe for sexual health and draws from the accumulated wisdom on MiddlesexMD—your questions, the blog posts, and my own thinking.

Response to the book has been wonderful. It was a banner year for interviews on various media outlets about the book and my work. I’m grateful for these opportunities to communicate to a broader circle of midlife women that they have options, that sex can still be rich and fulfilling, and more importantly, that they are not alone.

When I began this endeavor, I couldn’t have anticipated how gratifying it would be to meet such resilient, independent, inquisitive women who are tackling life’s challenges gracefully and well. I’ve been honored to share this journey with you and to provide some support and information that may make the experience easier and, I hope, more joyful for you.

So, my friends, here’s to good health and good sex. Thank you for sharing your journey with me.



December 22, 2016


health care ›   menopause ›   NAMS ›  

Q: How do I find a menopause doctor in my city?

I know it can seem like ob/gyn offices are full of pregnant women! And while general practitioners can be extremely helpful, sometimes you want the extra training and focus of a menopause care specialist.

You asked. Dr. Barb answered.I recommend finding a menopause provider in your area by going to the North American Menopause Society (NAMS) website, where you can enter your zip code and specify a mile radius to find a practitioner near you. Note that you can also check the box (NCMP) to limit the search results to NAMS-certified providers, who have completed additional focused training and receive ongoing updates on research and recommendations from the society.

December 15, 2016


estrogen ›   hormones ›   HT ›   menopause ›  

Q: Should I Go Back on HT?

The symptoms you describe--moodiness, depression and anxiety, hot flashes, sleep interruptions, less sensitivity in nipples and clitoris--are all consistent with stopping the hormone therapy (HT). Sensitivity to the effects of hormones varies among women, and you’re definitely in the “responder” category!

You asked. Dr. Barb answered.You mention that you discontinued the HT because of concerns for long-term health. It’s important to consider the form of HT you’re using: The Combipatch that you were using is a transdermal estrogen (and progestin) delivery method, and that method has significantly less risk for stroke or thrombosis. If estrogen is taken orally, it is metabolized through the liver, which increases a blood clotting factor and puts women at a slightly greater risk for stroke and blood clots. Transdermal (through the skin) delivery doesn’t pose the same risk, because it bypasses the liver metabolism and enters the bloodstream directly.

You’re in your 50s, fit, and low risk: You’re a perfect person to consider continuation of HT for all the reasons you mention. It sounds like HT definitely improves your quality of life, which is to me a determinative factor. We don’t really have a clear time frame in which we know that HT starts to pose additional risk.  

December 08, 2016


arousal ›   menopause ›  

Q: Is oral stimulation only for younger couples?

You say you’ve read about oral stimulation in She Comes First. Congratulations on continuing to learn about sexuality and your own body!

You asked. Dr. Barb answered.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.”

How to Keep Your Bladder Healthy

Bladder health may be far from the most riveting of conversations, but trust me, a bladder that behaves itself will make your life a whole lot more enjoyable, and that includes your sex life, as well.

As we discussed in the last post, bladder misbehavior in the form of incontinence and urinary tract infections (UTIs) is a common female complaint, and it tends to become more common and more troublesome as we age. This is because decreasing estrogen affects genital tissue and muscles in unhelpful ways.

You don’t need to check out adult diapers just yet, however. Not only are treatment options available, depending on the type of incontinence you have, but you can develop some common-sense  bladder health habits that will tune up that tired organ and may even roll back some of the age-related changes.

  1. Do Kegels. This critical exercise for strengthening and toning your pelvic floor is your first line of defense for any weakening, sagging, or leakage. In several studies, Kegels were the one non-surgical treatment for incontinence that actually seemed to make a difference. “Overall, there is strong evidence that pelvic muscle training can significantly improve sexual health in women with stress and urgency UI respectively,” conclude the authors of one study.
  2. One way to challenge yourself and to ensure you’re exercising the right muscles is with Kegel weights or balls. Firm up those pelvic floor muscles, and you’ll help all those downtown organs stay where they belong. Kegels may not completely end all your incontinence issues, but they are the place to start.
  3. Stay hydrated. It sounds counterintuitive, but drinking plenty of plain water will keep your system moisturized and it will help prevent UTIs. The only caveats are not to go overboard with the hydration and perhaps not to drink liquids close to bedtime if nighttime urges wake you up.
  4. Avoid caffeine in all its forms. Caffeine isn’t hydrating, and as you know, it just makes you pee more. If you’ve got a Diet Coke habit, be aware that carbonated drinks combine caffeine and carbonation as bladder irritants, adding to the urgency and frequency of urination.
  5. Drink cranberry juice. While overly acidic foods and beverages may not sit well with your system, cranberry juice, while not a definitive cure, proves beneficial for some women. Tablet forms may also be effective.
  6. Lose weight. Excess avoirdupois puts extra pressure on the pelvic floor, bladder included. Losing weight and staying active can help prevent episodes of both incontinence and UTIs.
  7. Pee before and after sex. If you tend to tinkle during sex (coital incontinence), remember to pee right before and right after having sex. This will help with both involuntary leaking and to prevent a UTI.
  8. Keep your bottom extra clean. Wash regularly with a mild, moisturizing soap to keep UTI-causing bacteria in check.
  9. Have sex. It’s like a workout for your pelvic floor, and it keeps tissues moist and supple.

10% discount on Kegel toolsDespite your attention to good bladder health, you may still experience bothersome levels of incontinence and UTIs. The next step is to talk with your doctor. Studies show that most women avoid this conversation because, well, it’s embarrassing. Let me assure you that we’ve heard it all, and incontinence is an incredibly common female issue. This isn’t something you should endure. Treatments are available, and they do work.

Depending on the type of incontinence you have, (urge and stress incontinence are the two major sub-types), treatment options could be very simple. With bladder training, for example, you set a timer and wait for increasingly longer periods before urinating to “retrain” the bladder (and yourself). This method coupled with Kegel exercises can cut urge incontinence problems in half, according to the National Institutes of Health.

There are a number of medications, including some new ones, that are very effective in treating urge incontinence. Your health care provider can help you weigh the options.

Since stress incontinence is more commonly caused by wear and tear on the pelvic floor (by childbirth, for example) as well as by normal aging and hormonal loss, medications are less effective in treating it. Topical estrogen, however, is a good option for rejuvenating tissue in the entire genital area, urethra included. It isn’t absorbed systemically, so it’s a good option for those who want to avoid extra hormonal exposure

A common and minimally invasive surgical procedure involves inserting a tiny mesh sling to support the urethra. This procedure is effective in over 85 percent of cases.

For most of us, some level of incontinence is an annoying fact of life. But it shouldn’t compromise our quality of life or cause undue embarrassment or anxiety. If you find this to be the case, it’s time for a talk with your doctor.

Use the promotion code SQUEEZE for a 10% discount on Kegel exercise tools, and increase your pelvic muscle tone. Offer expires December 17.



November Is… Bladder Health Month!

And what, you ask, does my bladder have to do with sex? 

Good question, but here’s the thing: When you think about it, all our sexual bits are tucked in a very tight space with all the “other” bits we use for elimination. They all cohabit the same anatomical real estate and pass through the same muscular sling (pelvic floor). If you question the wisdom of our anatomy, pity the poor hyena, who copulates, urinates, and gives birth—with great difficulty—through the same tube.

Since all those organs are clustered in one anatomical region, they are also all sensitive to any change of flora or pH balance or hormones that might happen in that space. In fact, what we now refer to as the genitourinary symptoms of menopause (GSM) is an umbrella term for the hormonal changes which affect the whole enchilada—pelvic floor, bladder, vagina, and all the associated tubes and musculature. (The bowels aren’t included, but they can also be affected by age and hormonal change.)

So, as vaginal tissue becomes more fragile due to loss of estrogen during menopause, so does the labia and the urethra (the tube from the bladder through which we urinate). Specifically with regard to the bladder, GSM exacerbates two extremely common female complaints: urinary incontinence and urinary tract infections (UTIs).

If you’ve had kids—and maybe if you haven’t—you’ve probably experienced the nearly ubiquitous stress incontinence of the cough-sneeze-pee variety. A second type of incontinence is overactive bladder (OAB) or urge incontinence. This is when you feel the need to pee suddenly, frequently, and urgently. In both cases, small—and sometimes large—leakages may occur.

Both conditions can either commence or worsen with menopause, and either can cause you to urinate a little or a lot during sex, usually with penetration or orgasm, when all the nerves in the area are stimulated.

Which could really dampen the mood.

Research on the effect of incontinence on sex is scarce, and honestly, that effect would seem pretty intuitive. Studies that have been conducted indicate that incontinence has a negative effect on sex (duh!)—and on life in general. The embarrassment and anxiety of constantly having to worry about peeing your pants certainly puts the kibosh on quality of life—and that embarrassment doesn’t stop at the bedroom door.

In one small study, every woman with OAB syndrome all expressed anxiety over its effect on their sex life, whether or not they were actually incontinent during sex (coital incontinence). Just the worry about whether they would pee during an orgasm was enough to create a psychological barrier to sex. The worse their condition, the greater the negative impact on sex.

“Overactive bladder with or without incontinence negatively affects women's sexual health, reducing sexual desire and ability to achieve orgasm,” the study concluded.

Urinary tract infections (UTIs) are the second sucker-punch to libido that accompany and can increase with age and menopause. Again, it’s all part of a syndrome in which loss of hormones makes our genitourinary tissue more fragile and prone to breakdown and, thus, infection. Our female anatomy—short urethra in a warm, moist location near our other orifices—creates an inviting greenhouse for bacterial growth. Ironically, even sex can cause a UTI because it invites the migration of bacteria from one spot to another.

Discount on Kegel tools through December 17But take heart! As with most things menopausal, prevention techniques and treatment options are available.  There are ways to mitigate the effects of GSM on the bladder and ways to prevent them. Not perfectly. Not always. But neither do you have to soldier on alone and in silence. That’s the kind of awareness that Bladder Health Month is all about.


Use the promotion code SQUEEZE to receive 10% off Kegel exercise tools, and up your pelvic floor muscle tone. 



November 17, 2016


menopause ›   painful sex ›  

Q: Sex is painful, but it’s not dryness. Help?

You asked. Dr. Barb answered.To know the ultimate solution for treatment of painful intercourse, it’s important to know the exact cause of the pain. If it is vulvovaginal atrophy, then a vaginal estrogen, like Estrace vaginal cream (which you say you’re using), or Osphena, a non-hormonal oral medication, should be helpful. But not every option works for 100 percent of women, so if this is the diagnosis and you are not responding, another product should be considered.

There may also be another diagnosis apparent after a thorough exam. The condition you describe may be vulvodynia, which is referred to by a variety of names including provoked vulvodynia, localized vulvodynia, or vestibulodynia. I normally hear a description of burning, tearing, sandpaper-like, usually near the opening of the vagina.

Another cause of pain can be vaginismus, which results from too much tone of the pelvic floor muscles and results in painful intercourse. It’s the involuntary spasm of the muscles, which prevents or limits penetration.

Please persevere to get both a diagnosis you trust and a treatment that’s effective for you!

November 14, 2016


intimacy ›   menopause ›   painful sex ›  

Q: What will make intercourse less painful?

You say you’re past menopause, which is defined as a year without menstruating. Intercourse has become painful, and occasionally you have some bleeding afterwards.

The condition that leads to painful intercourse in menopause is vulvovaginal atrophy, now called genitourinary syndrome of menopause. The absence of estrogen leads to profound changes to the genitals. The vagina and vulva shrink, and the tissues are more dry, thin, and fragile. This leads to painful sex. Within five years of menopause, up to half of women have pain with intercourse.

Early in menopause, before the atrophy is advanced, vaginal moisturizers can be beneficial; they are considered part of prevention. But once the atrophy is more advanced, moisturizers are not enough.

You asked. Dr. Barb answered.You can restore health by adding a localized (vaginal) estrogen or using Osphena (an oral, non-estrogen treatment). Both of those options are prescription therapies that reverse the atrophy and restore health to the vagina, vulva, and lower urinary tract. A good lubricant is definitely important too, I recommend Pink, a silicone lubricant with aloe and vitamin E.

Occasionally, there can be an additional cause--beyond atrophy--for painful intercourse. A careful examination by a menopause care provider will help determine the exact cause and whether any additional treatment would be helpful.

Best of luck! With patience and persistence, most women can regain comfortable and satisfying intimacy!



November 07, 2016


aging ›   grandmothers ›   menopause ›  

We Are the Orca!

What Killer Whales Can Teach Us about Menopause

Can anyone guess what we have in common with female orcas (killer whales}?


That’s it. We share menopause with only two species on the planet, and both are whales: the orca (killer whale) and the pilot whale (which is technically a dolphin). All other mammals, including gorillas, chimpanzee, elephants, dogs, cats, and camels continue to bear young, albeit with decreasing frequency, until they die. No other mammal experiences literally decades of post-reproductive life.

Except us and the whales.

Of course, the big question biologists ask is, Why? From a Darwinian perspective, bearing young assures the continuation of the species. Decades of life without fertility makes no evolutionary sense. (According to biologists; we, on the other hand, might feel otherwise.)

Now, after decades of closely observing a specific pod of killer whales in the Pacific Northwest, biologists have greater understanding of the role female elders play in the whale community. The almost eerie parallels to our human experience have piqued the interest of scientists and writers, who think perhaps the way of the orca may shed light on human menopause.

For years, scientists thought human menopause was simply due to medical advances that enabled women to outlive their normal genetic lifespan. Without the intervention of modern medical technology, so the thinking goes, we too would bear children until we died, like our close mammalian cousins. Evolution, remember, favors traits that support the passing on of a species’ genes.

Enter the orca.

Female orcas stop calving in their 30s and 40s, but they continue to live for many decades beyond that—well into their 80s. “Granny,” the oldest of the Northwest orcas, is thought to be over 100 years old. After decades of observation, including hundreds of hours of underwater video, scientists began to understand that these old gals weren’t just freeloading on their sons and daughters. They were critical to their survival.

Orcas mostly hunt salmon, stocks of which vary, sometimes greatly, from year to year. It is the older female orcas that tend to lead the pods, and this is especially noticeable when the salmon stock is low. During lean years, the older females more frequently lead the clan. At those times, the accumulation of knowledge and experience by the older females give the orca a critical edge.

“That kind of knowledge is accumulated over time—accumulated in individuals,” said Darren Croft, professor of animal behavior at the University of Exeter in this article.

Studies of death rates were also revealing. The whale clans are matrilineal, with sons and daughters staying with the mother for life. Mature sons are so dependent, in fact, they are called “mummy’s boys.” They leave the clan periodically to mate, but they return to follow their mothers. When an older female dies, her sons and daughters are more likely to die as well. In fact, a son is eight times more likely to die within the year after losing his mother.

While these characteristics don’t exactly parallel human experience (we don’t tend to enjoy having our aging sons follow us around), they do point to the critical role of older females to the survival of the clan, whether whale or human.

Recent studies of hunter-gatherer societies reinforce this hypothesis. Given the long and costly job of raising human children to adulthood, grandmothers play a critical role in the well-being of the family, often taking on the role of forager-in-chief and caregiver for a daughter’s children.

It’s called the “grandmother effect.” Evolutionary biologists hypothesize that these contributions of an older woman offsets the decades of infertility. The grandmother assures that her genes are passed along by making sure that her grandchildren survive.

By no means do the grandma orcas take a back seat to the kids. They remain spry, vital, and active into their advanced years, maintaining their role as guide and coach. But the old gals have also been seen cavorting sexually with young males, presumably to teach them a thing or two about the birds and bees—and the cetaceans.

“Besides being the repository of knowledge about where to go in case of lack of food, they also lead very rich lives,” says Deborah Giles, director of the Center for Whale Research.

And so do we. This evolutionary state of affairs wherein we enjoy decades of vigorous, post-reproductive life while contributing to the well-being of our kin and the world in general is a pretty happy state of affairs, I’d say.

If the whales are any indication, far from being redundant, useless, or invisible, we continue to fill important and meaningful roles after menopause, which we have garnered through years of experience.

“We complain, women of my age, of becoming invisible, and it's trueyou realize how very much you're defined by sexuality. But I have a sensegalvanized by stories about the killer whalesthat now is the time when you become the person you really want to be," writes journalist Christa D’Souza, author of The Hot Topic, a book about menopause.

“The idea of women passing on information; the idea of wisdom with agethere's a beauty in that that is about something other than being able to reproduce.”