Want Better Sex? Mark Your Calendar.

It’s interesting to me how many patients who come to me with concerns about diminishing libido are there because of their husbands or long-time partners. These lucky women have a great relationship with a great person, and they don’t want anything, including their own lack of sexual desire, to jeopardize it.

I respect that. I think that the desire to keep a long and satisfying relationship intact is a good reason to want to want to have sex.

I also believe that a lot of women in this situation sell themselves short. They think that because their partners want to have sex more often than they do themselves, there is something “wrong” that they need to “fix.” Often, it’s just a matter of timing.

Being “in the mood” for sex comes more easily to men. A man who is physically healthy and capable of an erection is almost always in the mood. Men are wired to go from zero to sixty on nothing more than a flash of leg or a lingering kiss. Women, on the other hand, tend to rely more on emotional or intellectual stimuli to reach a state of physical desire. And that takes time.

My advice? Get out your trusty planner and schedule a date for sex. Think of it as extended foreplay. If you schedule a week in advance, you’ll have days to think about your date night--what you’ll wear, what he might say about what you’ll wear, how he will want to take whatever you’ll wear off you. You’ll have time to buy some candles, choose a new aromatic massage oil.

Most importantly, because you’ll have to synch your calendar with your lover’s, you’ll have time to anticipate and talk about sex with each other, to make the crucial emotional and intellectual connection that helps both of you get in the mood for physical intimacy.

Some people dismiss scheduled sex as unromantic or think that deep physical attraction has to be “spontaneous.” I think it’s important to distinguish between sex that happens spontaneously (which can be very nice!) and sex that includes creativity and spontaneity in the act of making love (also very nice!). Think of scheduling sex as a way of insuring that you and your partner have a space and time where spontaneous acts of love and erotic play can occur.

Sexual Variety in America: Forty-One Ways to Love Your Lover

We're learning. I was happy to see that confirmed by Indiana University’s Center for Sexual Health Promotion's findings in the latest National Survey of Sexual Health and Behavior.

I was glad to see that more Americans of all ages report they are engaging in a variety of sexual acts in addition to -- or instead of -- vaginal intercourse. Compared to the last survey, in 1994, more people are masturbating (alone or with a partner), giving or receiving oral sex, and generally experimenting with a medley of different sex acts: 41, to be exact.

And that doesn’t even include the use of sexual aids like vibrators.

This is good news for everyone, but especially for women -- and especially for women of a certain age. As this latest study confirms, women are less likely then men to experience orgasm during vaginal intercourse without additional stimulation. And as we get older it takes often takes additional additional stimulation to get the kind of sexual release we got used to enjoying in our 20s and 30s.

Feeling free -- and knowing how -- to mix it up, to combine several ways of making love in a single sexual encounter, makes it easier for women and the partners who love them to experience the full range of intimate pleasure.

The National Survey of Sexual Health and Behavior found that women were more likely have an orgasm if their partners used more than one technique in bed. Fifty-four percent of women who had “one-act” sex during their last encounter reported having an orgasm, while 89 percent of women who included five sex acts in their most recent assignation enjoyed orgasm.

Another piece of good news from the study: among women 50 and older, solo masturbation was more commonly reported than most other sexual behaviors. To me, this suggests that masturbation is not only less taboo among older women that it once was, it also indicates that more women are actively maintaining their bodies for sexual enjoyment. As a doctor who specializes in the health of women over 40, I’m a strong advocate of self-stimulation. It helps us remain sexually healthy and responsive (not to mention in a good mood) during times when we are without partners. When we have partners, it can help prepare genital tissues for comfortable intercourse and/or orgasm.

You may not aspire to all 41 acts. But if you’d like to expand your sexual repertoire, our website offers information and products that can help you expand your knowledge and pleasure. Branch out!

Sexual Satisfaction: All in Our Heads?

I saw a headline that irked me in Salon.com’s Broadsheet a week or two ago. I couldn’t quite put my finger on why it bothered me until I wrote a post about the cancelation of the flibanserin project last week.

The headline was “Forget the pink pill, try a placebo.” The article opened by saying that “Researchers are desperate to discover ‘female Viagra,’ but Cindy Meston says sugar pills might hold the key.”

Meston, a clinical psychology professor at the University of Texas at Austin, co-authored a study, published in the Journal of Sexual Medicine. Reviewing data from an earlier clinical trial of a drug treatment for low sexual arousal, she noted that about one-third of the test subjects who were given a placebo instead of the actual drug reported they had more “satisfying sexual encounters” during their “treatment.”

The Broadsheet reporter takes these findings as “a reminder that in the rush to ‘treat’ female desire, there is one organ researchers can’t forget: the brain.”

That’s a conclusion I certainly agree with: Mindfulness influences our sexual behavior. More simply, when we think about sex, we have more sex.

So let me get back to what bothered me about that headline: Yes, the brain is a critical and often under-estimated part of women’s sexual response. But it doesn’t function alone. It requires and interacts with hormones, which trigger physical responses that depend on our circulatory systems and tissue health. And the brain functions within the context of our histories and cultures and relationships.

Suggesting that a placebo is the answer for every woman’s sexuality oversimplifies and trivializes the issue. (In most clinical studies, by the way, placebos get about the same 30-percent response rate, so this study isn’t remarkable by that measure.)

Meston herself isn’t proposing that placebos are the answer: “Expecting to get better and trying to find a solution to a sexual problem by participating in a study seems to make couples feel closer, communicate more, and even act differently towards each other during sexual encounters.”

That’s definitely the first step—to be intentional about taking control of and improving our own sexual experience, involving our partners when we can. Any pattern at all that helps to focus our attention will help—whether it’s a before-bed routine with a partner, a sensual lotion that’s part of our self-care, or even taking a sugar pill.

But if that’s not enough, it’s because while it’s in our heads, it’s also not in our heads.

In Search of Hot Lit

We’ve written before about our efforts to find erotica to recommend to our growing MiddlesexMD community (Hi there, community!). Our efforts are are purely pragmatic, you understand. By subjecting ourselves to hours of film, reams of erotica, searing our eyeballs with the online offerings — all off this sacrifice, all for YOU, we are looking to find the good stuff, the stuff that really does, in fact, heat up a grown woman. (Real life experience has a way of turning an awful lot of porn and romance into comedy, we have found.)

If you haven’t been following the posts here, let me explain briefly: In menopause, our circulating sex hormones dimish. That can sometimes, not always, lead to a drop in libido. Even when the libido is willing, becoming aroused enough for sex can take a little time and effort. We need to step in, do the work our hormones did for us when we were young.

An easy and inexpensive way to adjust to this new reality is to give ourselves more opportunities to have sexual thoughts -- i.e., watching sexy movies, reading sexy literature, masturbating, wearing/doing sexy things.

Sexy literature… That's my subject. I've been poking around just a bit, looking at collections of erotica, some of it good fun, much of it yawningly dopey. While I’ve been looking, I’ve been thinking about the guideline we established during our silly, foiled movie night: We much prefer a Great Story That is Sexy to a sex story.

Enter Jacqueline Carey. When I think of great stories that are sexy, she springs immediately to mind. Her New York Times bestselling Kushiel’s Legacy Series encompass great epic tales full of romance, politics, turmoil, grief, tragic loss, breathtaking triumphs, and plenty of sex. Most of the sex is great, some of it is frightening, but all of it is integral to the storyline. I love that. Her novels are fat and involving enough to keep me diving into them night after night. Sexy enough to keep me on the edge of my libido for hundreds of pages.

So, why not ask the author herself about “Great Stories that are Sexy”?

I put the question to her, and waited. At first, coming up with a list stumped Carey too, which made me feel a little better about coming up with so few recommendations of my own. She's trolling for answers among her friends, too, but did come up with a starter set. Ms. Carey says:

*Try Diana Gabaldon's "Outlander" series.
*For fun, sexy fluff, Janet Evanovich's "Stephanie Plum" series.
*I don't know how well it stands the test of time, but I thought Colleen McCullough's The Thorn Birds was hella sexy and a good read back in the day.
*And check out Smart Bitches, Trashy Books for romance reviews. The genre's come a long way in the past decades.
I feel as if we've finally got a foothold on Hot Lit. The birth of a canon. But it's not really very big, is it? We need to feed this list. And for that, we need to hear from you. What do you think? Have you found writers whose work does it for you? Please share. We will keep adding to the list and will republish it as it grows. Those of us who read constantly need a steady supply…!

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

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

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

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

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

The Flibanserin Decision: Is the FDA Condescending to Women?

I have had women in my office, losing sleep, depressed, miserable, because the lack of intimacy where it is wanted can have a domino effect, destroying communication, trust, a couple, a family. For these women, overcoming our ancient biological responses to stress — in a modern world where stress is constant — is what they want and need, and as a doctor, I would like to be able to help them. View full article →

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

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

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

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

Sex: Deciding to Just Do It

We are learning more and more about what motivates women to have sex -- enough to know that we still don't know that much.

We do know that our motivations change with our situations. What motivates us when we're young and single is very different from what motivates us when we're older, and in long-standing relationships, or older and single.

So when we suffer from lack of desire -- are we missing the sort of drive we had when we were teenagers? And is it possible we just haven't found a new motivation for sex?

The more we learn from women, the more it seems that for us sex doesn't always begin with lust, but instead starts in our hearts and minds. We engage in our heads first, decide to have sex, and then with enough mental and emotional stimulation, our genitals respond. The older we grow, the more this is true. Age and maturity bring a new game into the bedroom.

For us, having sex is less an urge than a decision. One we can choose to make and then act upon. When we decide to say yes instead of no, decide to schedule sex instead of waiting (perhaps for a very long time…) for our body to spontaneously light on fire, decide to engage with media or methods that will put us in the mood rather than wait for romantic moments to happen along, we're using our heads to keep sex in our relationships.

Deciding to be intimate unlocks the pleasure. And the more sex we decide to have, the more sex we will feel like having. That's the secret to regular bonding.

Why just decide to do it? This much we know:

* Sex leads to a longer life.
* Sex, like all exercise, helps protect us against heart attack and possibly stroke.
* Hormones released during sex may decrease the risk of breast cancer and prostate cancer.
* It bolsters the immune system.
* Sex before bed helps us get to sleep.
* Of course, sex burns calories.
* Sex can help relieve chronic pain, including migraines.
* An active sex life is closely correlated with overall quality of life.
* Good sex can protect us against depression.
* Good sex reduces stress and increases self-esteem.
* Sex with your significant other stimulates feelings of affection, intimacy and closeness.

Making sex a focus in your life as you get older doesn't make you unusual. A study by AARP found that 66% of women age 45-59; 48% of women age 60-74 and 44% of women over the age of 75 believe that a satisfying sexual relationship is important to their quality of their life.

We think those numbers would be higher if women knew they could engage in thoroughly satisfying sex without waiting around for desire. Just by using their heads.

Let's Get Aroused

Hi everybody. My name is Julie. I’m a writer here at MiddlesexMD. My credentials for writing about sex at midlife are… Well… I have reached midlife. And I enjoy sex.

Still.

Despite almost 30 years of togetherness with the same guy. Despite aches and pains, stress and too little time, and all the physical surprises of menopause. Despite all of that, we are nowhere near ready to hang up our sheets.

So when my own friend (we served undergraduate years together) and doctor (my own menopause doctor, because I’m lucky), Dr. Barb, asked me to help her develop her website, I jumped at the chance. I needed to learn about this myself. What better way?

I’ve been writing for years and years, and for many years researching and writing on health  topics. But I have never written about sexual health. Barb is teaching me—you would not believe the size and density of these textbooks.

So, day one, lesson one, Basson’s Model. I had no idea that there is a difference between Sexual Desire and Sexual Arousal. I really always thought they were the same thing, or flip sides of the same impulse, or something. Because that’s the way I’d experienced it for most of my life. Arousal and Desire arrived on my doorstep, it seemed, instantaneously.

But they are considered distinct aspects of the sexual experience. And now that menopause has slowed me down a bit, I understand better.

We can achieve arousal with or without desire. We can have comfortable, enjoyable, emotionally satisfying sex with or without desire. That is, we need arousal for sex. But we don’t need desire. We like it. We want it. We enjoy it. But we don’t need it to engage in sex or get a lot out of our sexual experiences.

The easiest way for me to tease these ideas apart is this way: Desire happens in your head. It’s an idea. Arousal happens all over. It’s physical. Certainly the idea can spark a physical response. But it works the other way more often for women. Sexual stimuli—physical sensations, emotional feelings, sights, sounds, smells—arouse us physically. Our arousal readies our bodies for sex and can breed desire.

So, when we start talking about the kinds of sexual problems women may experience with menopause, the distinction becomes very important. Are we having difficulty with arousal or with desire? Or both?

What used to follow automatically from sexual stimuli—the arousal part—may now take more time and more stimulation. We may have to ask for and give ourselves more help and support to become aroused. This isn’t a lack of desire, but a greater need for stimulation.

We may be receiving all the same sexual stimuli that we always have, that always worked before, but we don’t respond to it as readily. We love our partners just as much or more. But our bodies just don't respond as quickly now. Or we may now have physical or emotional limitations or illness or medications that muffle the effect of sexual stimulation.

This was lesson one for me. A real eye opener. I used to worry that I didn't feel the same desire as I did when I was in my 20s and 30s. Worry isn't the word. It upset me. I am much more relaxed about it now. I'm learning to tune in to stimulation, to appreciate and notice my body's response more. And that helps a lot. Well, I suppose writing about sex every day doesn't hurt either...

There have been and will be many more lessons. Some embarrassingly basic. Some I wish I’d known 30 years ago. I will always be willing to show my ignorance in these matters, followed by Dr. Barb’s patient teachings.

Meantime, I’m gathering up all my favorite stimulants: I’m with Reka, a visitor from the last post, on the potency of Dr. Gregory House. And Dr. Andrew Weil too (his relaxation tapes have an opposite, unadvertised effect on me). I have a thing for David Strathairn. Indian food. Tango/dance movies. And I have this special drawer in my bedroom….  And you? Care to share?

(Anonymous sharing is always welcome. Or make up a name, if you like!)