The Big "O": For Him

We talk a lot here at MiddlesexMD about female side of sex, how to keep your libido alive and your sexual experience comfortable and pleasurable.

But we often take the male orgasm for granted (or… maybe not, at this stage of the game). For most of us—at least in the beginning, that pump was always primed; the shotgun always loaded. Now, whether our partner is slowing down, in need of a little pharma assistance, or still willing and able at the drop of a pin, we know for certain that his orgasmic experience is different from ours.

For starters, its purpose is different; the plumbing is different; and the “sexual-response cycle” (a term coined by sex researchers Masters and Johnson) has a different timing (say, like a hair-trigger).

On the other hand, male and female orgasms do share basic similarities in that both genders progress through similar stages. And, as with its female counterpart, a lot is still unknown about the male orgasm.

Since a little knowledge is a helpful thing, understanding what happens during a guy’s orgasm might help us appreciate the similarities and differences of our mutual experience. Maybe Mars and Venus can orbit in slightly greater harmony.

The male orgasm is designed to position healthy, active sperm so that it achieves its biological objective—babymaking. The job involves the coordination of brain, nerve, muscle, and blood, and psychological factors, to get those swimmers into our receptive vessel.

Testosterone is the juice that fuels the system in a male. It’s the critical hormone that keeps his libido finely tuned and his sexual apparatus running properly. Testosterone can boost our libido too, but a guy’s daily testosterone output is about 20 times greater than ours.

Testosterone is produced in the testicles, which also makes the sperm and mixes it with a protein-rich fluid bath for nourishment during the arduous trip up the vagina. Sperm and fluid together constitute semen, which is what is ejaculated during orgasm.

Usually (there are some exceptions), a guy has to have an orgasm for the pumping mechanism to work. For us, orgasm is nice to have, but not essential to the job at hand. Our orgasm might help those little sperms along somewhat, and it makes sex feel good, but orgasm or no, we can still get pregnant.

The actual sexual-response cycle unfolds in four stages for both men and women. For a guy, however, orgasm is a more straightforward and less tricky process. Given a normal anatomy and normal testosterone levels, a flash of nicely turned thigh or bosom is enough to trigger the first stage of the male orgasm: arousal.

We experience arousal too, of course, but it generally takes different stimuli and a longer time frame.

During arousal, blood flows into a guy’s penis through enlarged arteries perhaps 50 times faster than normal, and veins that normally drain blood from the penis close off. Muscles tense and the scrotum pulls inward.

Voilà! Erection.

The second stage is the plateau, in which the man’s body prepares for orgasm. Heartrate and blood pressure increase. Muscles tense further. Involuntary pelvic motions begin. A clear pre-ejaculate fluid may change the PH balance in the urethra so the sperm has a better chance of survival.

Orgasm in men occurs in two phases. First, semen collects in the urethral bulb at the top of the penis. This is called “ejaculatory inevitability,” in which the man reaches the point of no return. Then, the rockets fire. Muscles at the base of the anus contract rapidly to pump semen through the urethra, and nerves deliver orgasmically pleasurable messages to the brain. The ejaculation phase is fairly reflexive and is controlled by nerves in the spinal column.

The final stage—resolution— is when our man rolls over and falls asleep and we’re left feeling all warm and fuzzy and yearning for pillow talk—or for more sex. But don’t jump to conclusions—he’s spent, literally. He loses about half his erection immediately; the rest fades shortly.

While we may not be fully satisfied after one orgasm, our man is. It takes a recovery period (called refraction) before he’s ready to go again. When he was 19, refraction may have lasted half an hour. Now, well, it’s a different story. This is when a little sleight of hand or toy action might help you out.

While the male orgasm is less affected by mood and psychological factors than ours, hormonal imbalances, physical issues, medications, and of course, aging can still muck up a man’s ability to become aroused or to have an orgasm.

So, the next time your man starts to snore as soon as the deed is done, you don’t need to take it personally. Blame nature.

Can We Talk? I’m Not Sure.

Maybe I was naïve. We ran into some issues with the launch of MiddlesexMD.com earlier this year: We couldn’t advertise on a popular social networking site. An article we submitted was rejected because of subject matter. We were “ineligible” for a medical site designation.

And I took all that in stride, with some disappointment, as an entrepreneur, and some concern, as a physician trying to get the word out to women that sex is good for you and still possible and pleasurable, well beyond menopause. But I’m a parent, too, and I understand that there’s adult content that can’t just go everywhere.

But in the last week I saw a couple of articles (one in the New York Times) about Zestra and the walls its makers were hitting in trying to advertise. If you’ve missed the story, a commercial for Zestra Essential Arousal Oils was turned down by TV networks, cable stations, radio stations, and web sites. When it was accepted at all, it was slated to run in the middle of the night. Rachel Braun Scherl, the president of the company that makes Zestra, says, “When it comes to talking about the realities of women’s lives, you always have some woman running in the field…. There’s a double standard when it comes to society’s comfort level with female sexual health and enjoyment.”

As evidence, Rachel points to the advertising for Viagra and Cialis. And that’s when I start to think I may have been naïve. I remember the first time Bob Dole came on my television, during prime time, when my daughters were in middle school and still watching TV with me. It was a little awkward, maybe, to explain to them what “erectile dysfunction” was, exactly. Now they’re old enough to snicker with me (in a compassionate way—I am a doctor) when we hear “in the event of an erection lasting more than four hours, seek medical attention.”

So this gets me thinking. Why can we be so public about an aid to a man’s sexual satisfaction, but not aids to a woman’s? Is it because Viagra and Cialis are prescription products for a condition that’s been named a medical problem? In the case of erectile dysfunction, have we successfully separated the erection from sexuality? Because women’s arousal and satisfaction are more complex (remember why we love Rosemary?), is it too difficult to make that same separation? Or is there really still a double standard, with men’s sexual satisfaction ranking higher then women’s?

I’ll keep thinking. And, I’m sure, gathering anecdotal evidence on both sides of my questions. I’d love for you to join the conversation.

Q: Why did I have pain and tightness during intercourse?

In menopause, in the absence of estrogen, the vagina narrows and becomes more thin and fragile. Even when you are lubricated enough, the tissues have likely lost elasticity and can’t comfortably stretch with intercourse. Some light bleeding represents the "trauma" to those tissues and usually comes from near the opening of the vagina or the vaginal tissues themselves.

Using a vaginal moisturizer (like Yes, Replens, or KY Luiqibeads) would almost certainly help. It may also beneficial to use dilators to try to get back more caliber or capacity (dilators literally stretch the tissues gradually). You might also talk to your health care provider about vaginal estrogen, also known as localized estrogen, which may be of benefit to you in restoring elasticity.

Don't give up! You can be comfortable again.

Your mom had sex.

I hate to be the first to break it to you, but your Mom had sex. She did. And it’s possible she even enjoyed it. View full article →

Talking about sex.

I live and practice in the Midwest, where open discussion about sex is just not part of the culture. Even among close-knit groups of girlfriends, it’s a rare discussion, at least not past a certain age. I’m trying to remember when I stopped talking about sex openly with my friends...

I remember it was a subject of great interest and fascination when I was very young. Whispers, conjectures, a lot of mis-information and tall tales. By high school, we knew more, the better informed among us bringing along the uninformed.  In college, we received a great deal more detail as data from actual, rather than fictional, experimentation became more commonplace.

I suppose it is marriage that closes our mouths. We may have been willing to share exploits or guess at sex before we chose our mates, but once we do, the walls of privacy go up, and silence rules our sexual lives.

And that’s okay, so long as we have opportunities to continue to learn and explore, and provided we have some source of information and aid when things aren’t working. Because, let’s face it, we aren’t trained in sexual techniques. There is no sexual master class. No black belt to earn. And sex isn’t always smooth sailing. Our anatomy isn’t flawless or consistent in its function. We need information as we grow and change sexually, and most particularly when we enter the menopause.

In some cultures discussion about sexual technique among same-sex family members and social sets is nearly endless. But in our Puritan-influenced culture, silence is golden. So what are we to do? It isn’t likely that we’ll change a whole culture any time soon.

Well, online, we have a real opportunity. Here, we can talk to and learn from each other without sacrificing the privacy and propriety we hold dear. The online environment we want to build is one where we can share reliable, well-researched information that will help us understand and share not just matters of sexual health, but of sexual technique, too.  A good, safe, monitored discussion place to learn from each other and from the research and writings of sexual health practitioners.

We are busy gathering a good collection of information, but we’ll want to hear from you, too. What has changed for you with the menopause? What questions do you have? What has worked for you? What have you learned from others? What experiences are daunting? What Aha!s can you share?  Post under your own name, or under another name you choose -- either way, we'd love to hear from you.

Our Secret Recipe for Sex after Menopause

The post title is just tongue-in-cheek, folks. A little health writing humor, poking a stick at the whole idea of health “secrets.”

We don’t believe in keeping information about attaining good health secret.

So here, today, long before going live with our website, we are happy to divulge our recipe for sex after menopause. The ingredients are:

Tada!  Whooot!!! We have balloons falling and confetti rising over here at MsMD headquarters!! How about you?! No?

Wait, No?

Maybe you don’t realize how hard it is to distill good-sex-after-menopause down to an easy-to-remember system? So let me explain: Months ago, we began our work with a hard look at the American Psychiatric Association's DSM-IV description of disorders contributing to Women’s Sexual Dysfunction (There’s a phrase we won’t use a lot around here, because it worries us. If we don’t yet understand Women’s Sexual Function, how can we comfortably describe its dysfunction?).

We embraced (and strive to remain mindful of) the point of view of women’s sexual problems developed by the New View Campaign, and their concerns about the medicalization of human sexuality. We reduced by our focus on peri-menopausal and menopausal women. Filtered all of these concerns through recent research and publications by members of the North American Menopause Society (NAMS) and the International Society for the Study of Women’s Sexual Health (ISSWSH).

We surveyed current literature on female sexuality. We added recent work by sex researchers and therapists and coaches, relationship coaches and mindfulness gurus.

That was the first step.

The next step was sorting all of the helpful advice, tips, skills, and learning into clear descriptions of conditions and pragmatic actions so that women in menopause can understand exactly what is going on with their bodies and what they can do about it if they want things to be different.

We didn’t go looking for the recipe. It surfaced from the work, organically. We began to see how all of the latest and best advice of medical, psychiatric, and sex researchers and coaches, seeking to help older women enjoy their sexuality, clustered into just a few central goals. What does a woman need to do to enjoy sex after menopause? (Assuming, of course, that she wants to enjoy sex after menopause at all. Because that is still her choice.)

1. Knowledge

She needs to know the physiology of menopause, so she understands what is happening when it happens, and especially that though her experiences are unique to her, she's not alone. And she needs to know some new sexual techniques that will keep sex enjoyable as she ages.

2. Vaginal Comfort

She needs to learn how to take care of her vulvo-vaginal tissues so that sex remains comfortable.

3. Pelvic Tone

She needs to learn how and why to strengthen and maintain her pelvic girdle to encourage circulation and maintain or strengthen her orgasms.

4. Genital Sensation

She needs to compensate for less blood flow and less sensitivity in her genital tissues by providing herself with more stimulation, more sexual sensation.

5. Emotional Intimacy

She needs what every woman needs at every age for sex to be good. Sex needs to be intimate. It needs to mindfully create and reinforce a real connection. There it is. No secrets. When we take our site live in April, you’ll get all the rest, descriptions of conditions that get in the way of achieving these five goals, actions you can discuss with your doctor or take on your own to enjoy sexuality for life, and products we have selected to help you on your way.

A Little Conversation About Mindfulness

Since launching MiddlesexMD, I have to say, my dinners have gotten a lot more spicy.

You know how it is when dining with buddies. It’s polite—required—for them to ask what you’ve been up to lately.

When I tell them about MiddlesexMD, you would think it might stop the conversation cold, but I’ve found just the opposite is true.

My friends do want to talk about this. It’s not surprising when men are there that they are a bit more quiet, but they are engaged, too. We all appreciate our partners’ attention to these discussions—because we’re not always alone with these changes. They affect our sexual partners, of course.

I had dinner the other night with an old friend. The subject of our conversation turned to the idea of how important it is, especially for long-partnered people, to keep their sexuality top-of-mind if they want to keep their sex life going. I talked about how older women, particularly, need extra stimuli (both physical and emotional) as they get older.

We need more opportunities to think about sex, consider it, fantasize about it, and more emotional intimacy throughout the day to find or sustain the mood.  Sex is like any pursuit, if you want to get better at it, it requires your attention. Some call this "work" Awareness or Mindfulness. And I think this dimension of a relationship is valuable enough to “do the work.” (Smile.)

It was a simple conversation. I didn’t think it had any sort of profound effect at the time. But I ran into that friend a few weeks later. She pulled me aside, and whispered, “Hey Barb! Thinking about sex more? It WORKS.”

I wasn’t surprised, if it works for me, it should for you too!

Gee, I love my job.

Female Anatomy 101

Writing for my gynecologist friend has included a lot of Aha! moments. I admit some of this learning makes me blush. It's not just because I blush when talking about sex—though I do. It's because I’m embarrassed when I’m caught not knowing things I think I should have known a long, long time ago.

So, I’m reading along in Dr. Barb’s enormous textbooks on female sexuality, when I come across an illustration of the clitoris, sort of like the one below. I nearly passed it over, because, what’s to know at my age? I've lived with this equipment for 50 years. I'd like to think I know my way around it.

But this illustration colored in the entire structure of the clitoris. Not just the glans, but also the shaft and the crus clitoris, or crura.

Excuse me… the shaft?... and the crura?

No.. please picture me picking my head up like a prairie dog, looking around my office, and asking the air...

“The shaft?!"

"And the crura!?!”

Somehow in all my curious, bookish, research-happy past, I never learned more about the clitoris than about the little buttonthe glansthe part that sticks out from the prepuce at the top of the labia.

Who knew my clitoris had legs? And a shaft, even?

But yes, indeed. It's practically a little penis under that hood. With long, long legs that extend waaay back toward the perineum, which fill with blood when I’m aroused.

Now, of course, the cool, rational part of my mind tells me I have enjoyed my crura—and possibly even the shaft—because they’ve been there all along. But I would have liked to know about them from the start. I can’t help but wish for a few years back in which I could quite clearly visualize my long, leggy crura.

What can we do with this information? Well, with age, the clitoris loses some sensitivity. We may find it useful to use warming oils and gels or vibrating sex aids to increase stimulation to the clitoris as we prepare for or engage in sex.

And of course, to do that, it really does help to know where it is.

Back to the books...

January 28, 2010

3 comments

menopause ›   sex ›   Under the Covers ›  


How I Came to Care about Menopausal Sex

...and why you should care too!

It began when I partnered with the local hospital in my hometown to evaluate local women's health services, looking for any gaps where additional services were needed. In the process, it became clear that our community needed and could support a healthcare practice devoted to the special needs and care of women who were past their child-bearing yearsthese special needs were largely ignored by existing providers.

I decided to transform my practice. That was 4 years ago. I studied and became certified by the North American Menopause Society as a menopause care provider, and while welcoming patients into my practice, used their questionaire—a thorough document that makes it easy for new patients to give me a comprehensive view of their symptoms and health histories. On that eight-page-long form there are just a few questions for women to answer about their current and past sexual experiences:

  • Do you have concerns about your sex life?
  • Do you have a loss of interest in sexual activities (libido, desire)?
  • Do you have a loss of arousal (tingling in the genitals or breasts; vaginal moisture, warmth)?
  • Do you have a loss of response (weaker or absent orgasm)?
  • Do you have any pain with intercourse (vaginal penetration)? If yes, how long ago did the pain start? Please describe the pain: Pain with penetration? Pain inside? Feels dry?

Well, I was amazed by the responses from my new patients. 60 percent of my patients have experienced a loss of interest in sexual activities, 45 percent have a loss of arousal, and 45 percent a loss of sexual response. And when I talked to them, they were:

  • Perplexed—because they don’t understand what’s changed.
  • Disappointed—because they expected there to be more .
  • Frustrated—because they don’t know what to do about it.

And when you carry those numbers from my practice to the rest of the countrywell, more than 44 million women are aged 40 to 65 in the US alone. Some 6,000 of us reach menopause every day. And at least half of us experience sexual problems with menopause. Probably more.

That’s a lot of disappointed women. And a lot of disappointed men too… I believe there can be more, and women don’t have to just accept the changes if they don’t want to. I see MiddlesexMD as a real caregiving opportunity: Make it easy for women over 40 to gather the information and products they need to sustain their sexuality after menopause.

And that could make everyone happier!