Q: How can I restore arousal after a complete hysterectomy?

You asked. Dr. Barb Answered.The loss of hormones (estrogen and testosterone) with a hysterectomy and bilateral salpigoophorectomy (removal of ovaries) is definitely a “hit” to sexual function for women (I assume based on your message that your ovaries were removed). The genitals are, as we say in medicine, abundant with hormone receptors. In other words, hormones play a big role in the health and functionboth urinary and sexualof the genitals. So now, moving on without those hormones, what to do?

For most women, it’s direct stimulation of the clitoris that leads to experiencing orgasm. In the absence of estrogen, there is less blood supply, and, in turn, loss of sensation and ability to arouse or orgasm.

  • A warming lubricant can stimulate circulation and therefore sensation.
  • If your orgasms are weak, you might use the Intensity regularly on your own to build your pelvic floor muscles, which are what enable us to experience orgasm.
  • Probably the most reliable tool to help in achieving an orgasm will be a vibrator. The genitals need more direct and intense stimulation now, and a vibrator is usually a great solution. There are many great options to consider on the website.

This can also be a time to consider treating the genitals with prescription treatments such as localized estrogen or the non-estrogen options, Osphena or Intrarosa. Using testosterone off-label can help women with arousal and orgasm as well.

I’d encourage a conversation with your healthcare provider to see if there are options that may be helpful for you. 

Good luck! I’m glad to hear that your husband is supportive in addressing this frustration for both of you!



It Starts with Thinking

My last blog post, about thinking about sex as we think about exercise to encourage us to keep our sexuality alive, reminded me of another article I saw a while back.

In “Men Don’t Think about Sex Every Seven Seconds,” Dr. Laura Berman set out to debunk the urban legend alluded to in the headline. She cited a study done at Ohio State University, which concluded that men think about sex, on average, 19 times a day; women think about sex about 10 times a day.

That’s a far cry from every seven seconds, which works out to somewhere over 8,000 times per day, if my math is right and assuming eight hours of sleep.

Now, that research was done with college-age men and women, and I’m willing to cross-reference the National Surveys of Sexual Attitudes and Lifestyles (NATSAL), recently completed in Britain, to guess that by midlife, the rate is reduced by as much as 60 percent. For women like me, that means thinking about sex three or four times a day.

I don’t know how that strikes you—as too much or too little! Laura made another comment in her article that resonates with what I’ve seen in my practice: Researchers “found that incidence of sexual thoughts were most highly governed by one’s own sexual belief system. …People who had anxiety, shame, or guilt around their sexuality were less likely to have sexual thoughts, while people who were comfortable and secure in their sexuality were more likely to have sexual thoughts.”

That’s especially important to us as midlife women. We get lots of messages that conflict with the reality that we are still vital, complete, sensual, sexual creatures. As we watch our bodies change—through childbearing, decades, illness, losing and gaining (and losing and gaining) weight, new wrinkles—we ourselves sometimes question whether we are still sexual, attractive to ourselves as well as to our partners.

Dissatisfaction with our bodies is hardly exclusive to us midlife women, sadly. But when it affects what we decide to do or not to do, it begins to matter more to us. You’ve no doubt seen articles about staying active, because the more active you remain as you grow older, the more active you’re able to remain. You keep muscle tone, bone mass, and balance only as you exert yourself.

The same is true of our sexual selves. Physically, being sexually engaged increases circulation to vaginal tissues, which naturally thin and become more fragile as we lose estrogen. It’s equally important that we’re attuned to the mental part of the equation.

Remember Stuart Smalley on Saturday Night Live? The nerdy guy with the affirmations? “I’m good enough, I’m smart enough, and doggone it, people like me.” What if we midlife women had affirmations for ourselves? Could we use them to both reclaim our bodies and nurture our sexual selves?

I’ll have to give that some thought. Possibly up to ten times a day.

Q: Why do I have pain and hypersensitivity?

What you describe—pain and a burning sensation around your clitoris—is most consistent with vulvovaginal atrophy. As we lose estrogen, the genital tissues thin, and the labia and clitoris actually become smaller. There's also less blood supply to the genitals. Beyond making arousal and orgasm more difficult to achieve, these changes can also lead to discomfort, and experiencing pain when you're looking for pleasure will certainly affect your sex drive and arousal!

Localized estrogen is the option that works best (and it's often a huge difference) for most of my patients, restoring tissues and comfort. Talk to your health care provider about the available options and what you might consider in choosing one.

A vaginal moisturizer can also help you restore those tissues, but I suspect you'll find that most effective in combination with localized estrogen.

Please do take steps to address your symptoms! If sex can be more comfortable and enjoyable for you, I'm hopeful that your sex drive will rebound.

Still Seeking Options

We’ve been following the development of Flibanserin, also called “pink Viagra,” since 2010, when its developer shelved it after hitting a bump in the road to FDA approval. Several years later, we were talking about alternatives, Librido and Lybridos, which were moving forward with clinical trials (and have not yet been approved).

We’ve just learned that the manufacturer that now owns Flibanserin has filed an appeal of the FDA denial, saying that other drugs have been approved with less data and more extreme side effects. And that’s reignited discussion about whether pharmaceutical products targeting women’s sexual disorders are evaluated on a level—or relevant—playing field.

Flibanserin, Librido, and Lybridos (and a small handful of others) are all drugs designed to play a part in awakening libido for women. They counter hypoactive sexual desire disorder (HSDD), in physicians’ terminology (the rest of us call it “not tonight—or tomorrow night, either” syndrome). There are, for context, a couple of dozen FDA-approved drugs for the comparable problem among men, including Viagra.

I don’t have the insider information I’d need to assert a double standard, although people I know and respect—like my colleague Sheryl Kingsberg—suggest there is one. Women’s health psychologist at University Hospitals MacDonald Women’s Hospital, Sheryl said, “There’s a double standard of approving drugs with a high risk for men versus a minimal risk for women.” The side effects for Flibanserin, for example, were reported as dizziness and nausea; Sheryl compares those to side effects of penile pain, penile hematoma, and penile fracture—all from a drug that was approved.

That does sound like some extra protectiveness of women. Given my focus on sexual health for women, I run into a lot of cultural expectations and hesitations; we Americans are still just a bit prudish when it comes to, especially, older women having sex. That’s in spite of what I see in my practice every day: Women themselves want to live whole lives, which means being physically active, emotionally engaged, and sexually active within their relationships.

I recognize that sexuality for women is complex, and there won’t be a “magic bullet.” For women, arousal and desire is a mix of emotional intimacy, biological responses, and psychological responses; a drug won’t address all of the components. But because I’m often working with patients to untangle interlocking causes of problems with sex, I’m eager for as many tools as possible, including pharmaceuticals.

As a physician, I also see the need to evaluate trade-offs and risks. I’ve talked before about the pros and cons of hormone therapy. For some women, living longer doesn’t really count if they’re not able to be active—including being actively sexual. “Pink Viagra” drugs may well require the same kind of close collaboration between women and their doctors to evaluate risks and benefits. Again, Sheryl: “Give women a chance to decide for themselves, within reason. There is no drug out there that has no risk.” In the case of Flibanserin, only 8 percent of testers said the side effects were bad enough to make them want to drop the drug.

These decisions by the FDA are also important because pharmaceutical research is done by businesses, businesses that can decide that one problem or another is too expensive or too complicated to take on. Sheryl sees this, too, saying, “My worry is that research in this area will dry up and will leave many women without a pharmacological option.”

One way to make your voice heard about the importance of continued research is by signing the International Society for the Study of Women’s Sexual Health (ISSWSH) WISH petition. Our sexual health is integral to our overall health, and we need more investigation and even-handed, common-sense consideration of therapies for women.

Latebloomers: The New “Gay and Gray” Generation

Chocolate/vanilla. Black/white. Either/or. By now we know that life is a lot more nuanced. It’s an infinity of shades of gray. (Also a lot more flavors of ice cream.) Recently, a quiet phenomenon is gathering steam that challenges the either/or notion of sexuality and attraction as well as the theory that sexual orientation—our attraction to boys or girls—is pretty rigidly in place by adolescence.

They call themselves the “latebloomers.” These are women who discover well into middle age and often to their utter surprise, that they are sexually attracted to other women.

In a previous post, I wrote about some studies that examined arousal in men and women. Men, if you recall, are turned on by straight-up heterosexual sex. (Gay men are turned on by scenes of homosexual sex.) And they made no bones about their level of arousal in their self-reports, which were totally consistent with their physiological levels of arousal, as measured by blood flow to their genitals.

Women, on the other hand, were turned on by a wide variety of sexual pairing, including scenes of primates mating, according to those same instruments. But they reported that they were only aroused by heterosexual sex, which was decidedly not what their bodies were saying.

Interesting, hey?

So, that makes me wonder about this groundswell of latebloomers. By and large, they are stable, mature, married women with children who had never before been attracted to women, but who suddenly and unexpectedly found themselves with feelings they had never experienced before.

As you can imagine, this realization is like a land mine in the middle of the kitchen floor, causing tremendous upheaval, both to the woman’s identity and, if acted upon, to all her close relationships. When mamma comes out as a lesbian, it can alienate children, shock extended family, and destroy marriages. (Although interestingly some women manage to continue living with their husbands, albeit in a renegotiated relationship. Others found their husbands remarkably sanguine once they understood that it wasn’t about some shortcoming in themselves.)

Women who’ve made this transition often say it’s like discovering themselves anew. “It’s as if you spoke Chinese and lived in Mexico, then went back to China and could suddenly understand everything,” says Micki Grimland, who left a 24-year marriage after realizing she was gay in an article for More magazine. “Being straight was my second language, and I didn’t realize it until I found my first.”

Science has come a long way from the time when homosexuality was considered a mental illness. Still, sexual orientation was thought to be partly genetic and fairly hardwired by the time a person completes adolescence.

Yet, maybe things aren’t so black and white. Maybe sexual attraction isn’t so rigidly defined, at least for women. Among women in their 40s who now live with a same-sex partner, 35 percent had been married to a man. Among women in their 50s, that number is over 50 percent; and 75 percent of lesbian women over 60 had once been married.

By contrast, “almost 100 percent” of men were aware of their homosexual tendencies when they got married, according to Eli Coleman, director of the human sexuality program at the University of Minnesota in the More article. “Many women, though, are unaware of same-sex attraction until they’re much older.” And I've heard some discussion that women, who value deep emotional connections and communication, find that connectedness more readily later in life with women than men.

“The Kinsey scale shows women’s sexuality as very fluid,” says Barb Elgin, a social worker and relationship coach.

There simply isn’t enough scientific data to make any firm statements about female arousal or sexual orientation or about how changeable and fluid it may be over the course of a lifespan. At this point we’re mostly relying on anecdotal evidence. But that may be enough to suggest a cautious and compassionate approach to the issue, especially if you know, as I do, several women who have made this difficult crossing.

Because life just isn’t black or white.

A Libido Boost over the Counter?

According to a recent New York Times article, women now have available a plethora of products meant to boost “feminine arousal.” And they’re appearing not behind the pharmacist’s counter, but in over-the-counter products in major pharmacies, right beside the Vaporub and Ace wraps.

Yahoo—I think.

Many of these products contain blends of botanicals and oils and “secret-recipe” ingredients designed to boost a woman’s sexual response. I wish some of them would carry more information for the user so that, for example, some oils aren’t unintentionally used internally when they’re best only for external massage. As with many beauty products, some strike me as setting unrealistic expectations (or even sending unfortunate messages), as with “anti-aging creams” for the vagina, clitoris, and inner thighs.

Few of these products have been objectively tested for efficacy or safety, so it’s a “buyer beware”—or, I’d rather say, “buyer be informed” marketplace.  Zestra’s oil is the only arousal product that has been subjected to a randomized clinical trial in which it “significantly” outperformed a placebo. Too many products are promoted with only survey results, which are not the same thing as a clinical trial.

As the Times article noted (and we’ve stated many times), the trouble with female libido is that it’s complicated. Everything from mood to culture and personal beliefs to hormonal imbalances can affect a woman’s ability to “get it on.”

And in fact, a woman’s lack of libido also affects her partner’s sexual pleasure. Dr. Michael Krychman, gynecologist and MiddlesexMD advisor, notes that men often neglect to fill their Viagra prescriptions because their partner’s sexual issues remain unaddressed.

Finding a one-size-fits-all silver sex bullet is like looking for fairy dust. Most of us have to develop a multi-pronged regimen to keep our sex drive functional, especially as we get older. We could abide by the Hippocratic principle to “do no harm,” and given that these products are, by-and-large, indeed harmless, and that they may do some good, why not give them a trial of your own? Use a site like ours to inform yourself about what might be worth looking for or avoiding (we have this advice, for example, about choosing a lubricant), and then make some room for some playfulness.

“Do they work for serious issues? No. But do they work to make your sex life more fun? Maybe. There’s certainly no harm in trying,” says Dr. Bat Sheva Marcus in the Times article.

An Open Letter: How to Really Turn Me On

Dear beloved partner of mine:

We’ve been together for a long time. We’ve weathered some storms; we’ve had our ups and downs. The kids are raised; the house is ours again. These should be our golden years, right?

That’s why we need to talk. (I saw you cringe.)

You don’t like to admit it, but things are changing for me. Yes, it’s the change. The hot-flash and mood-swing change. The big M.

Maybe you’ve noticed that I don’t lubricate as well during sex and that it takes me longer to become aroused. In fact, maybe you’ve noticed that I’m not “in the mood” much, or rather, I’m in a lot of moods, not all of them pleasant. That’s because my emotions are on a trapeze, my body’s changing, and so is the way I feel about sex and the way it feels to me.

And because I want our sex life to be fabulous in our golden years (I’ve read that after menopause, sex is often better than ever), I want to share some of the stuff I’ve learned. This may require some adjustment on your part, but in the interest of a happy, satisfied, sexy wife, it’s worth it. Right?

Let’s start with a little quote from a friend, influenced, I think, by Shakespeare:  “Tup my mind and you can tup me.”

There’s a deep truth in that colorful nugget. Sex begins in our minds long before our bodies kick in. If you want good sex, here are some ways to get my mind in the game:

  • Make me feel valued, desirable, beautiful. Maybe I’ve gained a few pounds; maybe I’m drenched in sweat at night; maybe I’m feeling old. But yours is the only opinion that matters to me. Look at me the way you used to. Bring me flowers. Tell me I’m beautiful—and mean it.
  • Listen to me. Turn off the TV. Don’t offer solutions. Don’t try to fix things. Validate what I’m going through. Don’t patronize me or belittle my experience. And don’t even begin to think that it’s “all in my mind.” This is just a rough patch, and frankly, how sexy I’ll feel toward you on the other end will have a lot to do with how attentive you are now.
  • So—be attentive, just to be supportive, not for sex. Make dinner or clean up afterward. Leave a love note on the dresser or a sexy text on my cell. Do small things that let me know you’re thinking of me. And not once or twice. Make this the new normal.
  • Work out with me. I’m not happy with the way my body’s changing. I don’t feel sexy, and I don’t feel confident. You can help by not only encouraging me to exercise and eat healthfully, but also by doing it with me. If we both diet and get in shape, think how much better sex will be—and maybe how much longer we’ll have to enjoy it!
  • Touch me. Just loving, compassionate touch without a hint of horniness. You know I’m a sucker for a good snuggle. You don’t? Well, it’s time you learned. A quick hug; a little shoulder massage after work; a nighttime cuddle—just to let me know you care.
  • Be patient. You may be a magnet for my moods, and not the mood you’re hoping for. Try to understand that my hormones have run amuck and that my body’s playing tricks on me, and that you (certainly not my boss or my mother) are the safest target. I don’t like it, either. Give me some space. Don’t take it personally. If I was once a nice person, she’ll be back, and she’ll be very grateful for such a thoughtful, supportive partner.
  • Be playful. Lighten up. Make me laugh. You don’t have to be seriously funny, just be a little goofy. Laughter releases all kinds of soothing juju, and it reminds us that life is good.
  • Educate yourself. Read this blog and the MiddlesexMD website so you have some idea about what’s going on with my sexual apparatus. Then you can be on board when I suggest trying lubricants or sex toys.

With your support, I’m going to come out of this stronger, sexier, and more sure of myself than ever. We’re in this together, Honey, whether you like it or not.

As one gynecologist said, “The key to a woman successfully going through menopause is the quality of the support she gets from her husband, or the man in her life. The major mistake a woman makes is to think it’s her problem, because she doesn’t want to stress [her partner] out. There is no such thing as an uninvolved partner.”

How to Give a Sexy Massage

I've talked before about the benefits of touch and said that we’d give you some tips on how to give a “sexy” massage. Well, here they are!

While professional massage therapists are trained to really work the muscles, our suggestions are more about achieving intimacy in a sensual, relaxing way. So it’s more about technique than strength. Giving a massage requires emotional generosity and presence, so take your time. Don’t rush and enjoy the moment alone together. And let us know how it goes!

What you’ll need: A firm surface, pillows, a clean sheet, warm oil, scented candles (or combine the two in oil-producing massage candles), and soft, romantic music.

  • In a darkened room, with soft music playing and candles lit (but out of the way) have your partner lie face down on a firm, flat surface, such as couch cushions on the floor, with pillows under the neck, knees and ankles. Cover your partner with the clean sheet, pulling it down to expose the specific areas where you’ll be working, starting with the neck and shoulders.
  • Rub a few drops of the warm oil into your hands.
  • Using both hands, start at the bottom of the neck and make firm strokes outward along the shoulder and at the top of the arm. Use long, pressing movements.
  • Press your thumbs in firmly at middle of neck and go round and round in small circles.
  • Use the thumbs to work into the muscles at the base of the neck. Pay attention to any knots or areas of tightness that you find here working firmly and slowly into the muscles, continuing to make tiny circles.
  • Next, lay one hand flat on your partner's shoulders, then press the other hand on top and rotate slowly.
  • Keep your fingers together and palms in full contact with the part you’re working on.
  • Glide your hands slowly down either side of the spine, back up the sides of the body. Keep your thumbs on each side of spine, using very little pressure in this area.
  • Begin using a kneading motion as you work toward the arms, biceps, buttocks and thighs. Just lift and squeeze the area, keeping your palms in full contact with the skin.
  • For small areas like soles of feet and palms, apply friction with your fingertips. To do this, anchor the area you’re massaging with one hand and use the other to deeply press and rub.
  • Have your partner flip over and repeat the same kinds of motions on the front side, moving down from the top, until you’ve covered every body surface.
Don’t worry about whether you’re doing it “right”! Your goal is to create new ways of connecting through the power of your touch.

The Magic Touch

More and more research is being done these days about the powerful effects of human touch, with study subjects ranging from newborns to NBA basketball players to sexually dysfunctional couples. And what researchers are finding is that touch is such a basic human need it should not be neglected. One scientist, Tiffany Field, PhD, director of the Touch Research Institute at the University of Miami School of Medicine, goes so far as to recommend getting some sort of touch experience for at least 10 to 15 minutes every day!

Whether by hug, massage, or a pat on the back, connecting physically with another person signals safety and trust; it’s so soothing that it can actually reduce stress and anxiety and lower blood pressure. That’s because touching releases two powerful natural hormones, oxytocin and serotonin. Known as the “love hormone” oxytocin (not to be confused with the pain-killer oxycontin) is thought to be connected to compassion, while serotonin increases feelings of pleasure or rewards.

Needless to say, intimate touching can also enhance your sex life. But it’s like everything else in our busy lives; if it’s not on our minds, we probably aren’t doing it as much as we should. Well, maybe it’s time to start.

Here are some suggestions:

  • Next time your partner has had a hard day, offer to give a nice massage. (More about “sexy massages” in a later post!)  Make an “appointment” for 15 minutes; then go into the bedroom, shut the door, put on some nice relaxing music and just rub your partner's back and shoulders, kneading gently in tense areas. (If you happen to have a tennis ball, it feels great to roll it over the neck!)
  • Offer a big surprise bear hug the next time your partner walks into the room. You’ll probably get a reaction like, “What’s that for?” so be prepared to answer with something complimentary. And remember: Giving a hug feels just as good as getting one.
  • When you’re driving somewhere in the car, or even out on a walk, reach over and grab your partner’s hand and just hold it for a few minutes, lightly stroking his fingers.

The more you start doing things like this, the more natural it will feel. And before you know it, that hug will lead to a caress… and the caress will lead to a kiss… and the kiss will lead to who knows what!

But it all begins with that one little touch.

Warming Oils and Lubricants: Hot Topicals

As we age, along with everything else we lose (our keys, our glasses, our hearing), it’s common to lose sensation in our genitals. Less sensation makes it harder to achieve arousal, which can lead to becoming less interested in sex. Blame it on lower hormone levels. One easy, inexpensive, and often fun way to stimulate the genital area is with warming oils or lubricants.

There’s a reason why when we become aroused, we feel “hot.” Blood flows to the genital area, creating a flush of warmth. Warming oils or lubricants are products that cause a chemical reaction when applied to the skin. They create a sensation of warmth that simulates the heat of arousal. It’s intended to feel good and to give us a little “leg up” to actual arousal.

Warming oils and lubricants may contain minty or peppery ingredients, or they may contain natural herbs, spices, or even vitamins that cause that a warming chemical reaction. Some may have added flavors or colors.

Use these warming products on healthy, intact tissue; don’t use them if you have any irritation or abrasion in your genital area. It’s also important to test a small area to make sure you like the feeling and don’t have an allergic reaction.

Warming lubricants that are water-based can be applied as you would any lubricant—a generous tablespoonful to your own or your partner’s genitals.

Warming oils are intended to be used only externally. Inside, they’re not conducive to good vaginal health, and they can also degrade the latex in a condom. You can spread warming oils on the labia, over the clitoral hood, and around the vaginal area. Some women like to include their nipples. Men like it, too, but avoid using oils on the penis if there’s a chance of vaginal penetration.

In addition to their practical function, warming lubricants or oils can add an element of shared pleasure to your sex life. And that can be arousing, too.