Delighted to Have Sex Again

Whether in person in my office or by email from the MiddlesexMD website, I hear variations on this story more often than you might think: A woman who’s been without a partner for years—often as many as 10—has found someone new. While she’s happy to have found a partner with whom to be intimate, she finds that sex is uncomfortable or even painful.

I celebrate the new relationship with each woman! While it’s perfectly possible to be happy on our own, it’s also lovely when we find a “right person” with whom we can share our lives and experiences—and intimacy, too.

When we find that right person after menopause, sometimes physical changes take us by surprise. Pain with intercourse is typically associated with vulvovaginal atrophy, which is the effect of the loss of estrogen. Women notice that they have less natural lubrication, and vaginal dryness makes friction painful. And the vaginal tissues are less elastic; the vaginal actually can shrink.

Both dryness and loss of elasticity can be addressed most simply with a lubricant. Silicone lubricants (our most popular is Pink) provide the most glide and last longest. Vaginal dilators can be helpful if, after a period of sexual inactivity, tissues need some gentle stretching.

Providing estrogen to the tissues is another option. There are prescription products that supply estrogen only to the vaginal tissues: Estrace cream, Premarin vaginal cream, Estring, and Vagifem are all localized options. Osphena is a non-hormonal option for treatment of vaginal and vulvar pain.

Some women describe a burning sensation on penetration, which may be caused by vulvodynia. Estrogen is part of the solution then, too, and a thorough medical exam would be helpful to determine exactly what treatment is needed.

Women who are sexually active after a hiatus also sometimes report the first urinary tract infections of their lives! There’s a movement to replace the term “vulvovaginal atrophy” with “genitourinary syndrome of menopause.” Both terms are a little clumsy, but the latter more accurately represents the reality of the effects of menopause: that there is a urinary as well as a genital component. Again, anything that improves vaginal health is a plus for the urinary tract; adding localized estrogen may be necessary. If bladder infections are recurring, using an antibiotic each time you have sex can be helpful to preventing them.

And! If you’re not in a relationship right now, whether or not you’re looking for one, be mindful of your body’s changes. If you’d like to keep your options open for the future, create your own maintenance plan; with some ongoing care, you can avoid the need to undo the effects of time.

Dusting Off the New Year’s Resolution

It’s March 1: Do you know where your New Year’s resolution is? You may be thinking, “It’s here, somewhere.”

I have a guess about where it is—collecting dust in a corner, where you left it when you “failed.” I’ve left a few there, myself.

Making a resolution is a positive step that makes it more likely we’ll change a behavior. But when we don’t follow through in the way we envisioned, that resolution becomes something that makes us feel worse about ourselves. When we don’t meet whatever goal we’ve set—whether it’s doing Kegels every day, ramping up a moisturizer habit, or setting aside time for intimacy—the easiest thing to do is give up altogether. “I don’t know why I even bother to make a resolution,” you might say. “I never keep them.”

I’d like to suggest that that’s a story you tell yourself. And the great thing about stories is that you can change them. In fact, research shows that telling yourself a different story has a lasting effect on performance. The researcher had students who thought of themselves as “bad at school” do a story editing exercise that included the idea “everyone fails at first.” Those students went on to get better grades and were more likely to stay in college.

So if you’re telling yourself that old story about your lack of self-discipline or your complete inability to follow through, stop. Retire that old story. Get yourself a new one. Tell yourself you’re learning how to integrate that new thing into your life, and learning takes time. Congratulate yourself on the effort. Look to the past for a time when you did follow through and change something about yourself or your life, and draw inspiration from it.

Then dust off that resolution—yes now!—and try again. Haven’t you heard? March is the new New Year.

A New Way to a Better You

As we mentioned last time, 47 percent of New Year’s resolutions are related to self-improvement—losing weight, quitting smoking, getting organized, or saving money. “Improving sexual health and wellbeing” doesn’t make the list (at least not the one in this study) but we think they should.

Because—let’s face it—chances are, they won’t magically get better on their own.

They used to, though, didn’t they? Or it seemed like it. Over the course of our relationships, all of us have probably experienced sexual desire come and go, as we went through things like pregnancy, health-related issues (for us or our partners), and times of stress. Looking back, we remember that desire always bounced back, as it does for most people who are generally healthy and on the young side of middle aged.

But at this stage of the game, how long should you let it go, hoping it will self-correct, before resolving to do something about it? Our take: Not long. Start now. You’ve got nothing to lose and so much to gain in the area of self-improvement.

Although we may not think of intimacy and sex falling into the “self improvement” category, it actually does. Do you want to lose weight? Be healthier? Feel better about yourself? Then get busy, sister, because having sex can help in all those ways. Equally as important is that when sex is good, as you’ll recall, it adds 15 – 20 percent additional value to a relationship; when it’s bad or nonexistent, it drains the relationship of positive value by 50 to 70 percent.

Make 2015 the year that you make a concerted effort at doing what it takes—kegels for better muscle tone, a vaginal moisturizer as part of your skin-care routine, lubricants or a vibrator to add some spice, an honest conversation about foreplay with your partner—to get your game on in the bedroom. Don’t just say you will; make it your New Year’s resolution. Research shows that if you make a resolution, you’re 10 times more likely to have been “continuously successful” at six months than if you don’t. Good luck and Happy New Year!

“Are Those What I Think They Are?”

I’m a gynecologist. I talk about sex and body parts all day long, and I have for 25 years.

I guess I take a certain amount of openness for granted. I see intimacy as a cherished part of relationships, and sexuality as a natural part of overall health. So I’m a little surprised more people aren’t talking about both!

That the conversations aren’t happening was apparent last week, when I spent a few days in the exhibit hall at a major conference for nurse practitioners. Every time I turned around, another woman (mostly, but also some men) was saying, I’m so glad you’re here! I get questions all the time, and I don’t know where to go for information or where to send women for resources.

At our MiddlesexMD exhibit, we had a cross section of our products on display, and found plenty of curiosity about some of them. Kegel tools probably led in prompting conversations, with vaginal dilators following. One woman nurse practitioner brought her husband by to show him, up close and personal, the first vibrators he’d ever seen.

There were a few gasps and a little blushing, but once our conversations got underway, I’m hopeful that these health care providers began to see our “toys” in a different light. Because yes, there are symptoms anyone in perimenopause or menopause can recognize: vaginal dryness and less sensation. And yes, many of us see intimacy as a part of our relationships that we’d hate to lose. And most definitely yes, there are things we can do—products we can use—that help us to compensate for changes and maintain (and even regain) our sexual health.

So, to the woman who came to our exhibit saying, “Are those what I think they are,” the answer is yes. And no.

Beyond being “sex toys,” these products are also tools for increasing blood circulation, strengthening muscles, and nourishing tissues. By keeping sex not only possible but satisfying, they’re reducing stress, improving cardiac health, combating pain and depression, and burning calories. If we think about them in that light—practically as medical devices—perhaps we’ll be more open-minded about adding to our repertoire.

There was plenty that was encouraging, even energizing, about my conversations last week. There are thousands of nurse practitioners—and other health care professionals—who are willing and prepared to talk. Every woman can help by initiating the conversation when they have concerns about intimacy or their sexual health.

You don’t have to talk about sex every day, as I do. Just don’t be shy when it matters.

Q: Can I regain my desire?

I wish there were a "secret sauce" that worked for all of us to restore libido. Not surprisingly, it's more complicated than that.

It's somewhat unusual to have an abrupt change to libido; for most women, it's a "slow drift." The first thing to consider with a dramatic change is any new or different medications. There are quite a few that have effects on desire: blood pressure, pain, and mood medications (antidepressants) to name a few. If you have had a change, you can work with your doctor to experiment with dosage or medications; let him or her know of this unintended side effect.

You ask about Cialis and similar products. They can help with orgasm (as they do for men), by arousing blood supply to the genitals, but they don't have an effect on libido or desire.

One option to consider is testosterone. While it's thought of as a male hormone, it's also present in women and is linked to libido. Some physicians aren't willing to prescribe it for women because it's an "off-label" use, but 60 percent of women report significant improvement in libido with testosterone replacement, and 20 percent of U.S. prescriptions for testosterone are now for women.

The other factor important to consider is mindfulness--which we might also call intentionality. While you may not feel desire that motivates you to be sexual right now, you know your long-time partner does. You can make the decision (together) that you will continue this activity together, including foreplay. (And I note a recent study that linked frequency of sexual activity with the quality of relationships, which confirmed my intuition.) When you make that decision, sex is a "mindful" activity: You anticipate and plan it and prepare physically and emotionally for an optimal experience with your partner.

Many women grieve the loss of a part of their lives that was once so important and fulfilling. It's most often an unnecessary loss, and staying sexually active has many health benefits as well as giving us feelings of both individual wholeness and connection to our partners.

Tennis? Or Sex?

There are many benefits to being sexually active: It releases estrogen and increases oxytocin, serotonin, endorphins, and immunoglobulin A. This chemical and hormonal stew makes us both feel and be healthier. Having sex makes us feel powerful, giving, and connected, all of which feed our relationships with our partners.

I came across a recent study that affirms another benefit I often talk to women about: Sex is good exercise.

MiddlesexMD_Couch

The study was conducted by Antony D. Karelis, who teaches exercise science at the University of Quebec at Montreal. Participants in the study wore armbands while having sex, and also jogged on treadmills to produce comparative data. The results? On the “metabolic equivalent of task” scale, on which sitting still ranks a 1-MET, sex ranked 6-MET for men and 5.6-MET for women. That puts it, according to Gretchen Reynolds, author of “Sex as Exercise: What are the Benefits?” as roughly equivalent to playing doubles tennis or walking uphill. To do your own comparisons, it’s categorized as “moderate exercise.”

Good to know, right? And I think we midlife women can use this knowledge to our advantage. Part of my counsel to women experiencing diminishing libido is to be intentional about remaining sexually active. There are two parts to my rationale: First, as our hormones diminish, we’ve got that “use it or lose it” thing going on that I’ve talked about before. Second, having sex begets having sex. That is, we women will want to have sex more often when we—wait for it—have sex.

There’s a line from the study conclusions that made me smile: “Both men and women reported that sexual activity was… highly enjoyable and more appreciated than the 30-minute exercise session on the treadmill.” I’m so glad to hear that!

So I start to wonder: How can we apply to our sex lives the same thinking that gets us religiously to yoga or Pilates several times a week? Neither we nor our partners want us to be thinking about sex as one more chore on the to-do list or an obligation on our calendars. But can we consider it a gift to ourselves and our health, as we do our morning walk or Zumba class? Will that give us the extra incentive to make the time and the commitment?

I’m hoping so.

July 25, 2013

0 comments

Condition News ›   sexual health ›  


A New Breakfast of Champions

It all began when entrepreneur Peter Ehrlich took a stroll through a vegan food fair in Toronto. If your livelihood depends on generating ideas, I guess that part of your brain never sleeps.

Suddenly, he realized that there was healthy, organic, non-GMO food for all kinds of health—except for sexual health.

This was Ehrlich’s Eureka! moment. Everybody eats cereal, he reasoned. Everybody wants to be sexy, and everyone wants to be healthy. Let’s bring it all together in one slick package.

Thus was Sexcereal conceived. After conception, the road to market dominance was easy. Ehrlich hired a “team of nutritionists and quality control experts” to create two recipes: one for “HIM” and another for “HER.” A very important step, apparently, was the packaging: a 300-gram bag of cereal with vintage, slightly come-hither, and very healthy-looking images of a guy and a girl. (The size of the guy’s spoon has gotten a lot of quips in the media.)

Besides a generous portion of rolled oats for both genders, which gives the cereal a granola-y look (Don’t call it granola, however; Ehrlich doesn’t like that.), the cereal “for him” has chia seeds, blueberries, black sesame and pumpkin seeds, cocoa nibs, bee pollen, goji berries, and maca powder. “She,” on the other hand, is indulged with wheat germ, soy protein, ginger, cranberries, almonds and flax seeds.

Sounds good, doesn’t it?

Sexcereal is described as a nutritious and tasty whole food with lots of fiber, iron, energy, and Omegas 3 and 6. It’s supposed to boost testosterone and promote hormone balance. Certainly, its makers want to be taken seriously as having created a good product.

But it costs $10 for that 300-gram packet, and it’s so popular that you’ll have to wait 10 days before your mail order is even filled.

The science behind the product? Not so much, as far as I can tell. Sexcereal’s success is all about the concept, the novelty, the marketing, and the media hype. Sex sells, as we all know.

So, maybe sample a packet of Sexcereal out of curiosity or send one as a gift to that person who has everything, but don’t expect a surge of white-hot passion. No matter what they say on TV.

"Return Decision Power to Women" on Hormone Replacement Therapy

It’s no wonder we’re confused. First it’s good; then it’s bad. Now it’s up to you.

Hormone replacement therapy has had more media makeovers than Liz Taylor, and it continues to grab attention here and there.

The latest, and highly credible, statement on the issue is from an international roundtable of medical experts convened by the Society for Women’s Health Research (SWHR). The purpose of this gathering of experts, which represented various specialties, such as cardiovascular disease, osteoporosis, and cancer, was to take yet another objective and rigorous look at the evidence regarding hormone replacement therapy, and to make recommendations as to its use and safety. The results of this discussion just came out in the Journal of Women’s Health.

This roundtable is a good effort to shed some objective light on the risks and benefits of an issue that’s been hotly debated for over ten years now, ever since the Women’s Health Initiative (WHI) prematurely ended its groundbreaking study of women receiving hormone therapy in 2002 because of a high incidence of breast cancer and cardiovascular complications.

The problem, however, is that hormone therapy (HT) is still the only effective, FDA-approved treatment for menopausal symptoms, such as hot flashes and vaginal changes. Recently two non-hormonal drugs were just nixed by an FDA advisory panel because they were viewed as ineffective.

Ever since the WHI results were released, the pendulum has been swinging wildly with each new medical release or research report. And while this latest SWHR roundtable really moves the chess pieces very little, it does solidly reaffirm positions held by the North American Menopause Society.

(In fact, NAMS had released its latest position statement on hormone treatment barely a month earlier.)

What the roundtable did add, however, is something I strongly advocate: Give women solid information about their treatment options and let them make informed decisions about their own health.

Their findings include:

  • In younger, postmenopausal women with menopausal symptoms, the benefits of HT outweigh the risks;
  • HT is the most effective treatment for osteoporosis and should be considered for the prevention of osteoporosis, especially among at risk women;
  • Contrary to popular misconceptions, HT for early, postmenopausal women does not increase the risk for coronary heart disease (CHD) and may even reduce it;
  • HT does not increase total mortality rates and may, in fact reduce them.

Here’s how the SWHR roundtable puts it: “It’s time to put HT back on the table so that women can discuss with their providers the option of symptom relief and possible long term health benefits.”

Amen to that.

Priming the Pump for Better Orgasms

I never knew what it meant to prime a pump until I watched a plumber work on one at my cottage. To prime a pump means to pour a little water into its fill cap to create suction and, with luck, to pressurize the thing so it draws water rather than spurting air.

The hydraulics metaphor may be more appropriate for men, but I’m betting that some of your orgasmic pressure has leaked out over the years, too. Or, maybe it wasn’t very dependable to begin with. According to some studies, from 25 to 50 percent of women have trouble achieving orgasm.

There are, however, ways to repressurize your orgasmic system—techniques that may help get the sexual juices flowing again. It’s not magic—there is still no pink Viagra that guarantees an orgasm, given that the female sexual response cycle is a lot more complicated than a water pump.

If your orgasmic mechanism needs a little priming, here some holistic ways to repressurize.

  1. Exercise. (I heard that groan.) Good orgasms require good circulation to keep all that oxygenated blood flowing to your genitals. Aging does a number on the blood flow and nerve endings in the genital area, making them sluggish and less responsive.  Exercise helps maintain good circulation. It also keeps blood circulating nicely to the brain, which, as we’ve said, is really your biggest sex organ.
  2. Kegels. C’mon. These are easy and painless (there are tools available), and they do you a lot of good. Kegels tone and strengthen your pelvic floor muscles; those muscles keep you from leaking urine when you sneeze as well as holding your internal organs in place. Strong pelvic floor muscles also create a firm “vaginal embrace,” which is nice for your man, but also gives you a more powerful orgasm.
  3. Check your medications. Several categories of drugs are libido killers, including some antidepressants, but also some drugs that reduce cholesterol and high blood pressure. If you suspect that your meds may be messing with your sex drive, talk to your doctor.
  4. Masturbate. You need good circulation down there, right? Self-pleasuring helps. It also helps you identify what you like and how to “do it” the way you like it—so you can tell your partner.
  5. Get a vibrator and other sex toys. There are all sorts of physical reasons to use a vibrator. (See #4 above.) Toys may help you release some inhibitions and learn to play.
  6. Drink a little (not a lot.) Sharing a little pre-sex cocktail can create a cozy sense of intimacy and also help lower your inhibitions. Drinking too much is a libido-killer. Share a glass of wine in front of the fireplace and move the action to the bedroom—or keep it by the fireplace.
  7. Fantasize. Think of it as your personal romance novel. You can sleep with anyone you want and do anything you want. You’re only limited by your imagination. Fantasy helps some women “get into their heads.” Try it.
  8. Positions. If you’ve been using your vibrator, you know where your sweet spots are, and the missionary position often misses them. Try the back entry “doggie-style” position which is good for hitting the G-spot, although not so good for the clitoris, or try sitting on his lap, which is good for all kinds of things.
  9. Foreplay. If you take seriously Esther Perel’s statement that, for erotic couples, “foreplay pretty much starts at the end of the previous orgasm,” you may extrapolate that good sex arises from consciously introducing sensuality into your relationship in a sustained way. Touch. Snuggle. Sextext. Write love notes. Introduce beauty and sensuality into your life that might leach into lovemaking as well.
  10. Have sex. This cannot be repeated too often. The more you have it, the more you want it, and the better at it you become. As one happily married husband said: “Practice, practice, practice.”

Q: Will I miss my cervix if it's part of a hysterectomy?

Most women have very normal sexual function without a cervix. I have seen reports that suggest an issue, but in 24 years of practice, I can't recall a single woman who was impaired by the absence of her cervix.

There are complications that result if the cervix is left after a hysterectomy, including abnormal pap smears and continued bleeding. If there is any remaining endometrium (the membrane lining of the uterus) and you consider hormone therapy in menopause, you will need progesterone as well as estrogen. I've seen women less fond of progesterone than estrogen.

Whether you're able to keep ovaries in a hysterectomy is a bigger issue to sexuality—and in fact overall health—for women. Even after menopause, the ovaries continue to produce hormones. Those hormones not only mitigate some of the effects of menopause, but they also promote bone and heart health. There are times when it's appropriate to remove the ovaries as part of a hysterectomy, but the decision needs to be made based on each woman's health and history.

Glad you're thinking about your continued sexual health, and good luck with your recovery!