Here’s an idea to spice up a holiday evening: Gather your coffee klatch girlfriends, or your BFFs, or even your sisters and/or daughters, make popcorn and margaritas, and watch “Love, Sweat, and Tears,” the new documentary about menopause.
Even better, snuggle up and watch it with your partner, because the red thread running through all the information about hot flashes and mood swings is that our sex lives don’t have to be disrupted or put on the shelf forever because of menopause. We can still be sexual beings; we can still be attractive; we darned well can still have sex.
The movie was a labor of love for Dr. Pam Gaudry, an ob/gyn who specializes in treating older women. After years of consulting with patients in the throes of menopause, Dr. Pam came to realize that of all the difficulties accompanying menopause, the most disturbing to many of her patients was the disruption of their sex lives. Losing this deep and intimate connection with loved partners was the most distressing part of menopause. And she knew that losing sexual intimacy is completely unnecessary.
Dr. Pam wants to educate women about menopause, about how to stay vital, healthy, and sexually fulfilled. She wants to blow up the social stigma surrounding menopause (that we’re dried-up old crones). “Women should look forward to this transition,” she says. “I want them to know what to do to protect their vaginas so they can have exciting, comfortable, and worry free sexual intercourse for the rest of their lives.”
In the film, Dr. Pam travels across America interviewing actors, comedians, clergy, medical professionals, as well as ordinary men and women about love and menopause. Joan Rivers is the headliner, in what turned out to be her last interview before her death in 2014. “I’m on a mission,” says Dr. Pam in her interview with Rivers, “to save menopausal vaginas in America.”
“Well, sign me up,” says Rivers.
In the course of the film, Dr. Pam interviews several colleagues that MiddlesexMD readers have met—Mary Jo Rapini and Dr. Michael Krychman. I make a cameo appearance, too.
Basically, Dr. Pam covers the same ground that we do here at MiddlesexMD because we have the same mission and message. She does it holistically, with humor and a lot of sage advice. “I want women to know why they must protect their vaginas,” she says. “I want estrogen in their vaginas when they’re going into the ground. And no woman should die without using a vibrator.”
Do not hesitate to gather selected friends and family and watch this movie together. For you and your honey, it’s required viewing. A pop quiz will follow.
Now let’s talk about what happens after the surgery. Specifically, what might happen to your sex life.
Usually, your doctor will tell you to wait about four to six weeks before having sex, depending on the type of procedure you had. You might want to clarify with your doctor exactly what he or she means by “sex.” Usually, that means vaginal penetration. So ask if oral sex is okay. How about using a vibrator or a hand?
When you’re ready for intercourse, you’ll want to start gently—lots of lube and gentle penetration. If the cervix was removed, it may take time for the top of the vagina (the “vaginal cuff”) to heal. Penetration may feel differently for a while. (Here’s a good metaphor for the process.)
Sometimes, emotional healing has to happen as well. After all, hysterectomy is the surgical end to childbearing. For some, depending on the reason for the hysterectomy, this is a relief; for others, it’s a significant and sometimes difficult transition. If you are overwhelmed by emotion or even depression, give yourself some time and space to heal. You may also need to seek out a listening ear or professional counselor to regain balance.
If your ovaries were removed, and you haven’t yet gone through menopause, or even if you’re in perimenopause, be prepared for the possibility of significant emotional and physical change. With the removal of your ovaries, hormone production suddenly stops, and you’re now in surgically induced menopause. This requires some preparation ahead of time and some patience and therapy after the procedure.
The good news is that, for most women, sex tends to be unchanged and is sometimes better. The parts necessary for orgasm are still intact, and the issues that may have caused the trouble in the first place (pain or bleeding) are gone. “Most women tell me that there is no change in the way they feel orgasm, and they are able to enjoy sex more since they don't have their original problem to interfere with sex,” writes Dr. Paul Indman.
This opinion is supported by several studies confirming that, for most women, sex is the same or better after a hysterectomy. In a small study of 104 women, researchers determined that the best predictor of the quality of sex after a hysterectomy was the quality of sex before the procedure.
Despite the research, some women say that sex just isn’t the same. They report weaker orgasms and less sensation, loss of libido, and difficulty with arousal. Therapies can help—hormone replacement, localized estrogen, lubes and moisturizers—but they can’t replace nature.
Furthermore, although the vast majority of women recover well, a hysterectomy is still a surgical procedure with all the attendant risks and uncertainties. Unexpected outcomes happen—nerves may be damaged; prolapse or fistula may occur. The long-term effect of removing significant abdominal organs is still poorly understood.
With that in mind, some tips for approaching this, or any, surgery might be:
Several years ago, an acquaintance had a total hysterectomy that included the removal of her ovaries. She was post-menopausal at the time, but sex was still very important to her and her husband. She was worried about the effect her hysterectomy would have on their sex life and discussed it with her doctor.
Recently she told me that there had indeed been a period of transition after her hysterectomy, but that over time, she had regained her former sensation, including the deep, pleasurable orgasms she had been accustomed to.
“I don’t know how it happened,” she told me. “I just worked from the memory of what sex had been before my surgery and focused on regaining that. And I did.”
Everyone’s experience is unique. It’s impossible to predict with utter certainty how an individual will respond to any surgical procedure. With a good medical team, good information, and a supportive partner, you’ve tilted the odds strongly in your favor.
Many of the women I see in my office would like a black and white answer: Where, exactly, are they on the path to menopause? What, exactly, can they expect? Unfortunately, I can’t really give them a solid answer, and here’s why.
Perimenopause—that period (no pun intended!) between regular menstruation and menopause—isn’t a steady progression. It’s more like two steps forward, one step back. Sometimes, one step forward, two steps back. You may have some signs along the way, like moodiness, insomnia, irregular periods, hot flashes, lack of interest in sex, or vaginal dryness.
Sometimes FSH tests are used to help fill in the picture, providing one more data point. I don’t often recommend these tests, though, because although the tests are accurate at that moment on that day, they can be wildly misleading—unless you’re not yet in perimenopause (in which case the test can point to other issues) or you’re in menopause—which you already know because you’re not menstruating.
Here’s what’s happening with FSH (follicle stimulating hormone): The pituitary gland sends out FSH to tell the ovaries to make estrogen, which helps eggs grow (stimulating follicles!) and thickens the uterine lining. The pituitary gland acts like a thermostat: if it senses estrogen production is low, it “kicks on” and releases more FSH.
But as I said, the path to menopause is not a straight one; most women have erratic periods before menopause. So even if you are 52 and have every other symptom of perimenopause, if you take the test during the one time in six months you happened to ovulate, your FSH levels would suggest you’re not menopausal. Lifestyle-related factors like stress and smoking also affect FSH levels, making them even less helpful.
Check out the graphic to see the kind of unpredictability that’s typical. The first graph shows regular hormonal fluctuation when you’re having regular cycles. The second graph shows how wildly all four hormones may vary over six months. The last graph shows that a consistently high level of FSH accompanies menopause. But, again, if you’re not having periods, you don’t need a hormone test—either from a doctor or an at-home saliva test—to tell you you’re menopausal. (If, by the way, you’ve had a hysterectomy, endometrial ablation, or another procedure that’s eliminated periods but you still have ovaries, you have the same unpredictability in hormone levels. Charting your symptoms for a few months may be the most helpful approach.) I understand that the ambiguity of perimenopause bothers some women. As a physician with a pretty good understanding of all the pieces at play, maybe I find it too easy to recommend that women tune in to their bodies and take it a month at a time. I'd love to hear from women who've found ways to be "in the moment" with The Change!
One of the advantages of having a medical advisor team is that I can hear reports from events I can’t attend! Michael Krychman, part of the team and medical director of The Sexual Medicine Center at Hoag Hospital and the Executive Director of the Southern California Center for Sexual Health and Survivorship, provides this update from a May meeting.
A resurgence of interest in female sexuality was apparent last month at the American Congress of Obstetricians and Gynecologists’ annual meeting. I had three presentations on female sexuality; menopausal sexual health and vaginal dryness were topics throughout the plenary and clinical courses. I completed a post-graduate course with Dr. Haywood Brown, Chair of Duke University, on Sexuality through the Lifecycle, which addressed topics like sexuality and pregnancy and postpartum; chronic medical illness and sexual function, including breast cancer; lesbian sexuality; and treatment paradigms for dysfunction. A brief, informative lecture on everything you always wanted to know about male sexuality for the female health care provider was also included in the core curriculum.
A sold-out luncheon session focused on emerging sexual pharmacology. Among the topics were new data about Flibanserin [which we’ve talked about before as “pink Viagra”]; intravaginal DHEA ovules, which may help with vaginal atrophy; PT141/bremelanotide as an option for arousal issues; and new lower-dose intravaginal estradiol for localized hormone treatment. There was also significant discussion about Osphena, which may be the first oral medication for vaginal atrophy.
A clinical seminar on Elderly Sexuality had over 100 attendees, who were very interested in learning about prevalence and incidence of sexual issues as women age; a comprehensive treatment paradigm was also presented. There were several updates on vaginal dryness and testosterone, too.
Even in the exhibit hall, sex was evident! Lelo, a premier self-stimulator company, was swamped with visitors during all hours. They introduced Intimina, their new sexual wellness line of products [which includes the Kiri, Raya, and Celesse vibrators]. Semprae Laboratories, makers of Zestra essential arousal oil, was swamped with interest over their new in-office physician retail program and distributed thousands of samples. The L’il Drugstore booth was busy with moisturizer Replens. Neogyn, a new vulvar soothing cream, was also on the exhibit floor. I even saw the Journal of Sexual Medicine floating around!
Medical support for women's sexuality has faced some challenges in the last few years. The FDA hearing on Flibanserin and the disappointing efficacy results of Libigel were a few recent set-backs, but in spite of them, attention to female sexual function and treatments for dysfunction looks to me to be going strong.
It is definitely an exciting and interesting time. The field of female sexual health and wellness is alive and thriving.
We’ve discussed the research: Older women “do it,” and like it, a lot! Beneath the sheets, we’re a lusty bunch, but get out on the streets, and we become invisible. No checking-you-out eye action; no swivel head. It’s hard even to get the attention of the guy in the hardware store if a young blonde is looking confused.
Older women are supposed to be genderless and unassuming. Certainly not sexy. Often, not even visible.
That’s a psychological sucker-punch to the self-image if there ever was one. So we wonder why, once we’ve begun (or completed) “the change,” we struggle with feeling all confident and attractive? When we are no longer fertile or full of hormones, are we still sexual? While we’re coping with a changing metabolism and whipsawing emotions are we still attractive?
In our time and culture, menopause is embarrassing and slightly distasteful. It’s synonymous with loss of fertility, loss of hormones, unmentionable changes “down there,” and growing old. Far from being regarded as wise and valuable, older women are often viewed as useless and sexless.
Maybe that cultural aversion is, in part, why we ignore things like incontinence, lack of libido, and painful sex—sometimes for years—because it’s embarrassing to admit that we may be having trouble with “the change.” Or experiencing menopause at all.
Wasn’t aging supposed to be graceful? Aren’t these supposed to be the golden years?
Without doubt they are. But to enjoy this time of life, we have to reject the negative voices all around us and in our heads. Maybe the way we look and, I hope, the way we look at life has matured. And maybe the way we do sex has changed. Maybe we need a little more time and a little more stimulation. Maybe we need more finesse and a few aids. But we still got it going on, girlfriend.
Here are some tips to get your sexy on:
I’ll leave the last word to a man who writes, “Now I check out the middle-aged women when I hit the grocery store, in the coffee shop, when I’m out running. I’m looking for that sexy confidence, that wisdom, that I’m vibrant and alive and I don’t care what you think about me sort of attitude.
So, ladies, what are you waiting for? Get your sexy on, for your special partner or for the potential one who might be checking you out in the produce aisle.
At MiddlesexMD, our approach to sex at midlife didn’t spring to life fully formed. In fact, it’s the result of a lot of thought and discussion about the kind of information women need during and after menopause to stay sexually healthy and functional.
We were concerned that a lot of the chatter surrounding sex during these years is based on hearsay and old wives’ tales, and it’s often cast in terms of dysfunction—of what’s not working right anymore. Also, in case you haven’t noticed, a lot is still unknown about normal female sexuality after menopause. (So let’s not be quite so quick to label it dysfunction.)
From my years in practice, I know that women don’t talk about these issues. They may associate hot flashes and mood swings with menopause, but changes that affect their sexuality aren’t widely known and don’t tend to enter into the doctor-patient conversation. I suspect that many women don’t exactly know what questions to ask.
So we envisioned MiddlesexMD as a forum and a clearinghouse for reliable, current information about changes to your libido and sexual organs during menopause. We also tried to organize this information in a way that is understandable and easy to manage. And that’s how we came up with the “Recipe.”
Our Recipe for Sexual Health coalesced after we reviewed a lot of research and looked at reports from the North American Menopause Society and the International Society for the Study of Women’s Sexual Health. We considered what sex therapists and researchers, counselors and relationship coaches, alternative medicine gurus and mindfulness gurus had to say.
We took all that information, mulled, mixed, and digested it, and voila! the ingredients for our Recipe rose like cream to the surface. Our website and our blog are organized around those five ingredients:
Knowledge. So you can understand what happens physiologically during menopause as well as learning some techniques for staying sexually healthy and functional.
Vaginal comfort. From my clinical experience, vaginal dryness and discomfort are the most common and annoying changes that women mention, and they happen to all of us. A lot of the information on our blog and the website discuss ways to maintain vaginal health.
Genital Sensation. So you can find ways to compensate for diminished blood flow and loss of sensation.
Pelvic tone. So you can understand why a well-toned pelvic floor is important, and how to develop those muscles.
Emotional intimacy. Because your body won’t respond if your heart and mind aren’t engaged. We feel this is, and always has been, the most important ingredient to a great sex life.
Since the launch of MiddlesexMD.com almost two years ago, you—our readers—have reinforced some of our educated guesses. How common and distressing vaginal dryness can be, for example. Also that sex for women is complicated. Unlike men, the path from stimuli to desire to arousal to the big O is far from linear. And the unpredictability of our responses only intensifies during menopause.
As we age, we can develop other heath conditions, like hypertension or diabetes. Then it becomes more difficult to tease out the effect of these conditions from sexual problems. Plus, both the physical condition and the medications used to treat it can affect sexual responses.
We’ve also come to appreciate the difficulty of putting some heat back into a long-term, ho-hum sex life (or maybe completely reinventing it).
You remind us that that sex is a very individual matter—certainly not a one-size-fits-all affair. That’s the beauty—and the challenge—of claiming, or reclaiming, your sexuality.
We’ve been impressed with the fact that, contrary to some stereotypes, we’re still pretty sexy ladies at midlife. We like having sex, and we want to keep on enjoying it. That’s what MiddlesexMD is all about—creating a forum and providing the information that will keep you sexy for a long time.
So, how are we doing? Do you have unanswered questions? Have we missed anything in the recipe? Can you find what you’re looking for?
Let us know, because we like many cooks working on our recipe.
Maybe your last child left home, as mine just did this fall. Maybe you (or your partner) retired. Maybe your partner became ill. The catalyst could be one of many life events, or it could simply be the realization of time passing, but at some point you look at your partner and realize that you’ll be spending the rest of your lives alone together.
Do you need to hit the “reset” button?
Life passages tend to elicit examination and reassessment. These bittersweet moments give you an opportunity to readjust and re-evaluate. They give you a second (and third, and fourth…) chance to get things right. You tend to be more receptive to feedback and direction during those times. You tend to be less complacent.
Chances are that after years of distraction—raising a family, building a career—your relationship needs some attention, and that includes the sex. “Sex is always where the grit of a relationship settles,” writes a reader to the UK’s Globe and Mail. In that sense, sex is like the canary in the coal mine—an early warning system that all may not be so copacetic in the relationship.
So, how is your sex life? Robust and satisfying? Routine and uninspiring? Or is it non-existent? If your answer falls into the “boring” or “non-existent” categories, it’s time to reset.
“When sex drops off there’s a lot more at stake than missing out on pleasure,” says Joan Sauers, author of Sex Lives of Australian Women. “A healthy sex life is critical to the survival of a relationship. Without it, our happiness and overall health can suffer.”
Begin with reflection. Is infrequent, boring, or non-existent sex perhaps an indication of deeper trouble—entrenched lack of communication, trust, or respect? Is it due to physical changes or limitations that you haven’t risked discussing? In this case, hitting the “reset” button should include some honest soul-searching with your partner and maybe some sessions either with a sex therapist or a marriage counselor. Simply addressing the sexual issues without tackling the underlying problem is like painting over rotten wood. The veneer won’t hold for very long.
However, working to improve your sex life ipso facto improves the relationship as well, because both rely on intimacy, connection, and communication. “Keeping things interesting outside of the bedroom also plays an important part in keeping things exciting in the bedroom,” writes Rhegan Lundborg, sex and relationships expert for the Omaha Examiner. “Doing new and fun things completely outside of the bedroom can be a great way to reconnect emotionally as well as take sole focus off the sex and just spend time enjoying each others company.”
Focus on reconnecting. In a quiet, intimate surrounding, reminisce about the day you met, your first kiss, what attracted you to your partner. Go through a photo album together. Talk about key moments in your relationship—adventures you shared, challenges you got through. Few people in your life know you as well as this person. That’s a rare and precious treasure. Make time to appreciate it.
From memories, move on to fantasies. In a perfect world, what would you like to accomplish or experience together—or separately? What’s still important?
Don’t be stingy with the sugar. Express approval. Say thank you. Notice the small ways your partner is thoughtful.
It takes time and careful tending to reignite a flame. As you rebuild intimacy on other levels, communication about your sexual connection could follow naturally. Or you may have to initiate the conversation when the time is right. Or—you may have to initiate the conversation with professional help.
Start the conversation in a safe, accepting, non-judgmental space. You both are likely to be experiencing changes, whether physical or emotional. You may have fears; you may be vulnerable. And you may also have fantasies—things you’d like to try but never had the guts to ask.
Isn’t it time to hit the “reset” button and get this conversation started?
In 1968, she was Barbarella, the fresh-faced ingénue in shockingly sexy outfits. Then she was Hanoi Jane protesting against the Vietnam War. She was the prostitute in the movie Klute, for which she won an Oscar for Best Actress. She became our Fitness Queen in 1982 literally inventing the workout video. The “Jane Fonda Workout” is still the bestselling video of all time (17 million).
Whatever you might think of Jane, she’s always been at the cutting edge, always willing to forge new paths, and she’s always relevant.
Now Jane is at it again, tackling stereotypes and pummeling barriers with her latest book, Prime Time, an uncensored examination of “love, health, sex, fitness, friendship, and spirit.” This time she’s taking on the stereotypes of aging. With a freshly remade face (about which she is unabashed) and characteristically toned body, she looks many years younger than 73. Yes, you read that right. Seventy-three. In a quintessentially Jane statement, she attributes her appearance to 30 percent good genes, 30 percent lifestyle, 10 percent plastic surgery, and 30 percent good sex.
As you might expect, Jane doesn’t pull any punches about the sex. She has sex, and she likes it. Her frank, 50-page chapter on sex in Prime Time (“The Changing Landscape of Sex When You’re Over the Hill”) is a refreshing peek behind a curtain that is ignored at best and considered unmentionable at worst.
Perhaps the first important revelation is that she is doing what she can to continue enjoying sex with her longtime boyfriend, music producer Richard Perry. She was on hormone replacement therapy until she was diagnosed with breast cancer in 2010. Until recently, she also took testosterone, which “makes a huge difference if you want to remain sexual and your libido has dropped,” she says. She stopped taking it recently when she developed a stubborn case of acne.
In her book, she discusses masturbation, sex toys, and resuming sex after a hiatus. After divorcing Ted Turner, she was alone for six years before meeting Perry. “If you have been celibate for a long time and then begin a new love affair, be aware that your vagina is likely to need some attention,” she said in a recent interview.
Jane’s done her homework, and her advice is solid. But her most important contribution is to broach a subject that is socially taboo. When a celebrity and role model talks about having sex at 73, it becomes okay for other people to talk about.
That was a conscious decision on her part. “I wanted to go into such detail about sex because it can be very important in later life,” she said. “There are all kinds of changes that no one ever tells us how to handle. One of the things I kept hearing from the sex doctors was that very few people come to them with their problems… So I thought it would be helpful to go into detail about that.”
She also reveals another little-known secret of aging in Prime Time—that it can be the best time of your life. People over 50 tend to be less hostile, less stressed, and more capable of maintaining intimate relationships. And the sex can be better, too. According to Jane, all this adds up to happiness.
Yes, vaginal dilators will help gently and gradually to assure that your vaginal tissues are stretched. I recommend using them one or two times a day for 20- or 30-minute sessions. The more you use them, the more quickly you'll get the results you're looking for.
Dilators come in graduated sizes, starting as small as a half-inch diameter and stepping up to 1 3/8-inch diameter. Take your time, and I'm sure your first experience will be a comfortable one! Congratulations.
When you exercise, you need more oxygen. Sex is like a light exercise—you need more oxygen then, too. For people with chronic obstructive pulmonary disease (COPD), such as asthma, emphysema, or chronic bronchitis, that breathing space may be hard to come by. Further complicating the physical condition is the emotional fear of not being able to breathe.
Taken together, these emotional and physical limitations present an obstacle to the carefree sex of former days. But just as you develop new ways to accomplish other daily activities, you can continue to enjoy a fulfilling sex life. You just have to make adjustments. Such as:
Stay in shape. Heard this before? To enjoy the highest quality of life possible, you need to be as healthy as possible. This means to continue to exercise and to maintain a healthy weight. Discuss ways to improve your health with your doctor. See if there’s a pulmonary rehab program in your area where you can learn safe ways to exercise. Your quality of life will be better, and so will the quality of your sex life.
Prepare the environment. For those with allergies or lung conditions, the bedroom is the most important area to keep clean and allergen-free. That means no fragrances, smoke, pet dander, or dust. Keep the mattress and pillows enclosed in allergenic covers. Use a HEPA filter on the vacuum and consider using one in the room itself.
Prepare yourself. In order to enjoy these intimate encounters, psychological preparation is as important as physical preparation. Think about what you need to feel secure during sex. How can you communicate with your partner if you begin to feel breathless? What can you do to approach intercourse as a pleasurable act without anxiety?
Some physical preparation can also help you feel safe and comfortable. Keep your inhalers at the bedside. Take a puff or two of your short-acting bronchodilator about 15 minutes before having sex. If you use oxygen, keep it bedside as well. Add tube extensions to the nasal canula so you have more wiggle room. Wait a couple hours after a meal to have sex.
Do it. Experiment with positions that take pressure off your chest—lying on your side or sitting on a chair, perhaps. Use pillows to help prop you up. Take it slow and easy—cuddling and touching are nice, too. Run a fan—cool air on your face can help ease breathing and diffuse any heat buildup in the area.
Use supplemental oxygen if you have to and stop if you get winded. Talk to your doctor about increasing the oxygen flow during sex.
Don’t overlook the many alternative ways to give and receive pleasure. You can use manual stimulation, for example, or use a vibrator on the clitoris and the underside of the penis.
When normal activities consume more energy, and fatigue is the shadow at your elbow, making love may seem like climbing Everest. But just as you find ways to accomplish those mundane tasks, it will be even more rewarding to find new ways to make love.