The Progress We’re Making

Birthdays are a useful thing—although it’s increasingly easier to celebrate them for our children (or grandchildren) than for ourselves. Here at MiddlesexMD, we’re celebrating a milestone: It was five years ago this month that we launched our website. While I’ve been practicing medicine for much longer (did I say it’s not easy to celebrate every milestone?), this marks five years of encouraging women to learn about and take charge of their sexual health throughout their lives.There are a number of ways to measure how far we’ve come, like marking our children’s height on a chart. The first that comes to mind is the number of women who’ve been in touch.

We’ve been in contact with hundreds of thousands of women (and men who love them) from 209 countries. Many have thanked us for solving a specific problem, or for simply providing some hope and a path to follow.

We’ve talked to hundreds of women in person, too, at medical conferences. Nurse practitioners and other health care providers have said how grateful they are to have a resource for patients and, because many of them are women, have shared personal stories, too.

As a physician, I have more options available to me than I did five years ago. Osphena comes to mind as a treatment for vaginal and vulvar pain. And while localized estrogen products have been on the market for a while, I’ve noticed more advertisements for them. While too much advertising—especially of pharmaceuticals—can sometimes just be noise, I see the ads as an increase in conversation about women’s sexual health. And that’s a good thing.

I’m hopeful about increased conversation at the FDA, too. Last fall I attended meetings to discuss how the agency reviewed and set priorities for drugs to treat women’s sexual health challenges. It’s been rewarding to join with colleagues in Even the Score, a campaign for women’s sexual health equity. In March, eleven members of Congress signed a letter to the commissioner of the FDA, expressing the firm belief that “equitable access to health care should be a fundamental right” and noting the disparity between the number of FDA-approved drugs for male sexual dysfunction (26) and female sexual dysfunction (0).

Yes You Can by Dr. Barb DePreeIt will take some time for new treatments to make their way through development, testing, and FDA approval. In the meantime, I’m also happy to note more books (including my own) and websites offering information, encouragement, and community to women as they navigate midlife and beyond. 

I hope you’re talking, too—to your partner, your friends, your sisters, and your health care provider. When we share our experiences, we feel less alone. And we can also learn from each other about what’s happening and what works to keep us vital and engaged. Because we know that even at—especially at—midlife and beyond, we’ve still got it!

“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.

Doctors and Shopping: The Follow-Up

In January, I was working on an article I'd been asked to provide to OBG Management magazine. They'd asked me to talk about why I offer products through my practice—which was, actually, the same motivation that led me to found MiddlesexMD: There are some simple products available that can help women remain sexually active, but it's not always easy—or comfortable—to buy them.

As I wrote the article, I wondered how you as patients feel about products being offered through your doctors' offices, so I asked. And a number of you responded, either on the blog or directly, with your thoughts. You were overwhelmingly positive, assuming that your relationship with your health care provider was one based on trust to begin with (and I hope we're all that fortunate!).

OBG Management published my article, called "Vibrators, Your Practice, and Your Patients' Sexual Health," in their April issue. Read it if you like, and take a copy to your next doctor visit if you think it would be helpful in opening a discussion about how he or she can be more helpful to you and your sexual health!

Thanks to all of you who voiced your support or concerns. We'll keep learning together—and stay as sexually active as we choose!

What Do You Think? Doctors and Shopping

I’d like to solicit your opinion.

As you know, (or… maybe you don’t) MiddlesexMD has an online store in which we sell all kinds of products geared toward the sexual needs and pleasures of older women—“for midlife women who want to enjoy sexuality for life,” as we say. And some products just for fun.

As I’ve explained before, I created this store for a generation of women who need more sexual stimulation, lubrication, and support, but who probably aren’t going to check out their local sex shop (assuming there is one) and who probably aren’t savvy or experienced shoppers when it comes to choosing items like vibrators or warming oils.

So my team and I did the shopping (when was the last time you went to an “adult” trade show?), testing, and selecting of products we thought would be helpful and safe for midlife women.

It wasn’t easy, let me tell you, but I’m proud of our selection, and I’m confident about the quality of their design and construction and the safety of their materials. Full disclosure: MiddlesexMD is a business, so there is some profit involved.

So what’s the problem?

Because I have this dual role—as a practicing physician and as MiddlesexMD, other health care providers ask my advice about product sales. I know that the doctor-patient relationship is a tender thing, and it’s based on trust. My patients trust me to use my skills on their behalf. They don’t want my commitment to their health and well-being diluted or divided by self-interest. Nor do I.

When doctors sell products, conflict of interest is always lurking. Can doctors be objective when they stand to make money by recommending this vitamin or that weight-loss aid? And wouldn’t patients feel some pressure to buy the product to please the doctor? Does the presence of the product in a doctor’s office imply that the doctor endorses it?

The fact that some doctors derive a significant portion of their income from selling these products in their offices reinforces that appearance of ethical shadow-boxing. A few “celebrity” doctors have become virtual mouthpieces for certain product lines, which often lack research as to their efficacy or even safety.

As you can imagine, the issue has engendered passionate discussion both pro and con within medical circles, and professional medical organization have yet to issue any guidance regarding the practice.

I can honestly say that my primary motivation for selling products that I’ve tested and sometimes use myself is to provide a tasteful, private, safe opportunity for women to buy intimate items that will help keep them sexually active and comfortable and that they’d have a hard time finding otherwise. I set prices comparable to other retail options.

I practiced medicine for years before bringing products into my office. My relationships with patients were well-established. And I’ve seen first-hand that women are more likely to follow through when I can show them what lubricants feel like or how a vibrator functions. When my patients can walk out with products they’re ready to use, rather than with one more research project for their to-do lists—well, I think that’s useful and convenient. I’m not sure I would still have an electric toothbrush if my dentist didn’t offer them for sale.

So I’d like to think I’m offering a valuable service to my patients, but can I truly be objective when I have something, however modest, to gain? Do my patients feel subtly obligated? Do I compromise my professional credibility?

What do you think? Service or self-serving? I’d really like to know.

What I'm Thankful For

Feeling gratitude and not expressing it is like wrapping a present and not giving it. —William Arthur Ward

The good thing about holidays is that they give us an opportunity to reflect (if we’re not too busy preparing for them) and to cultivate good old virtues, like generosity and gratitude. Holidays encourage us to express things, like love and appreciation, that we don’t get around to in the normal course of daily life.

Thanksgiving, of course, is a time for gratitude.

So this holiday gives me a great opportunity to tell you that I’m really grateful for the many people who support and value the work we do here at MiddlesexMD. This work wouldn’t be possible without all you supportive people.

Six years ago I refocused my clinical practice to serve the sexual health needs of women in midlife because I discovered that so many of us were struggling with the physical and sexual changes brought on by menopause. Women, I learned, needed advice and guidance but didn’t know where to look for it.

Now, MiddlesexMD has its own website, newsletter, and blog. We have an online boutique with an array of tasteful, helpful, and woman-tested products to help keep the sexual flame alight. In fact, we’ve become one of the go-to resources nationally for information about sex at midlife.

That’s pretty impressive, if you ask me.

There are only two ways to live your life. One is as though nothing is a miracle. The other is as though everything is a miracle. —Albert Einstein

As I see it, MiddlesexMD is sort of a miracle. The amazing thing is that so many people are involved, interested, and in so doing, have contributed to its success. We have a small army of people who spread the word about what we’re doing, and give us support, encouragement, help, and advice along the way.

We turn to members of our MiddlesexMD advisory board frequently on this blog. We have a fabulous board whose members represent some of the leaders in the field of female sexual health. Despite their own busy practices, they’re always willing to share their expertise with MiddlesexMD readers. So—members of our great MiddlesexMD advisory board—thank you!

We also have a creative and hardworking internal team that plans, organizes, and runs all the disparate parts of this venture and helps to keep me sane and focused. I’m incredibly grateful to the amazing team that operates behind the scenes. MiddlesexMD wouldn’t be here without you.

Gratitude can transform common days into thanksgivings, turn routine jobs into joy, and change ordinary opportunities into blessings. —William Arthur Ward

Finally, no foray into social media is successful unless people spread the word. MiddlesexMD is successful because other practitioners tell their patients about our site and because readers “like,” tweet, "share," and tell their friends about us.

To all of you who spread the word—thank you so much. And don’t stop!

Gratitude is a vaccine, an antitoxin, and an antiseptic. —John Henry Jowett

Finally, let me leave you with a little Thanksgiving Day doctor-ish prescription. (You knew this was coming.)

Studies repeatedly link gratitude with higher levels of satisfaction with life. Grateful people are happy people. They pay attention to the positive stuff. They focus on the good and deal with the bad, sad, or difficult when it comes along. This isn’t denial or wishful thinking. It’s a choice that gradually becomes a habit.

So, along with a healthy diet and regular exercise, I’m prescribing a dose of gratitude every day before breakfast. It’s cheaper than pharmaceuticals, and who knows, it might even make sex better, too.

What are you grateful for right now? Who makes your life joyful? Have you told that person how you feel? 

October 15, 2012

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NAMS ›   NPWH ›   sexuality ›   Under the Covers ›  


Friends in Florida

The MiddlesexMD team and I have just come back from representing what we do at two conferences in Orlando. The first was the gathering of the North American Menopause Society; the second was the Nurse Practitioners in Women’s Health.

These events are both exhausting and exhilarating. It’s great, as a medical professional, to learn from the presentations by my colleagues on topics I’m dealing with every day, whether in my office or by responding to questions on or researching products for MiddlesexMD. Both physicians and nurse practitioners are enthusiastic about what we offer—a safe place for both solid, reliable information about sex after 40 and private purchases of products that can help address changes many of us face. We met other people who share our mission of making sure women know that they can continue (or start!) to have comfortable, satisfying sex, no matter what their age.

We’ve been doing these events for a couple of years now, in a variety of places. We’re reminded—as I certainly know, investing in my continuing education—that medical professionals always have things to learn—and are eager to do so. They’re surprisingly up front about wanting information for themselves as well as for their patients. We love the women who come back to our booth on day two of a conference, having discussed their sex lives over dinner the night before! And we’re also touched by the woman who steps away to call her husband before she chooses a vibrator. We love to see all that conversation about our sexuality!

There are, of course, a lot of professionals at these conferences—people who talk about body parts and processes all day long. But we’re especially happy to talk to hotel employees who happen by, who may have fewer opportunities to have their questions about sexuality answered. We met Linda, who picked up information for her friend who’s just recovering from a hysterectomy, and Tony, who was deputized to pick up information for his coworkers to share with their midlife wives. Our fellow exhibitors are also welcoming; we exchange information about how we support women and are often able to share resources.

As some of our new relationships develop over the next few months, I’ll share details here. For now, just know there’s a whole community of people out there who are ready to help you maintain your sexual health. And we at MiddlesexMD are pleased to be a part!

Together but Alone

I hear from a number of women that although they’re in long-term relationships, they’re feeling alone. Sometimes this becomes apparent as part of adjusting to other changes—like sending the last kid off to college, welcoming a parent into the household, or adapting when one or both partners retire from a career. I asked MiddlesexMD advisor Mary Jo Rapini, a psychotherapist who specializes in intimacy and relationships, what women can do when they find themselves unsatisfied.

The loneliest feeling doesn’t come from being single. It’s being married or living with someone, but feeling alone. This happens when one of the partners checks out emotionally but eats there, does their laundry there, and sleeps there. For all other purposes, though, there is no partnership. This happens to couples who live together as well as couples who date and marry. Many times some type of crisis precipitates a partner’s emotional distance, but sometimes it just happens. You may sense your partner no longer values your judgment. You may notice your partner no longer listens to you, talks to you, or wants to engage with you.

When a woman first begins to feel lonely in her relationship, she doesn’t automatically get help. She’ll usually try to understand what is going on in her partner’s life. She may ask, “You okay?” or “What’s the matter?” Those questions are usually answered by, “Oh, just work,” or, “I’m just tired.”

Sometimes the partner will come back with, “Nothing I say is good enough, and you fight me on everything.” When this happens, the partner who asked the question begins feeling even more alone and more stuck in her loneliness. They may reach out to friends or family, or begin reading self-help books. Her friends may validate that her partner is cruel, insecure, having an affair, or all of the other things friends try to do to make one feel better. The bottom line is, she’s in a bad position. She is committed to someone and very much alone.

The amount of distance in a relationship is determined by the couple and the style they develop. Many of us like more distance between ourselves and others, and this is reflected in how we relate. Just as some people are very private and others extremely open; some couples cannot go to the grocery store without the other, and some travel across the world without each other. It’s a personal preference; neither is right or wrong.

Feeling alone is much different than actually being alone. Feeling alone means the communication is broken. Your partner may be in Africa and you in Texas, but if you are talking on the phone and sending silly texts or emails, you’re together. If he is at your side, but no longer engaging with you, talking to you, wanting to be with you, he might as well be in Africa.

As with most things, this emotional distance is easier to prevent than to fix once the damage is done. But here are three steps to take to feel less isolated in your relationship:

  1. Ask yourself if you really want this relationship. Sometimes we become lonely when we long for someone or something else. Your partner may sense that you’re not communicating that you feel stagnant or want out. Your partner may be withdrawing as a way of limiting—or pre-empting—the hurt.
  2. Talk to your partner about how you feel. Does your partner know you feel unloved or distant? No one can read your mind. It’s possible that your partner is feeling the same distance and will welcome you raising the issue.
  3. Are your beliefs about money, sex, or faith getting in the way of your need to be connected with one another? Couples who are fighting may project the anger from the disagreement onto the relationship. The distance created is actually about disagreeing over a topic. If you talk about this, it will help bridge the distance you feel.

Our relationships are a way to receive—and to give—the love, acceptance, and security we need to grow and evolve. To be physically and emotionally alone in a committed relationship is unbearable because the hope of connection is lost. Study after study has shown what happens to babies who are isolated from human love, acceptance, and security. We never outgrow that need.

If you still feel stuck, get help. Couples therapy has helped thousands of people reconnect. And if your partner isn’t interested, a trained, objective counselor can help you to evaluate where you really are and what your options might be.

The G-spot: Defined but Not Demystified

Remember the G-spot brouhaha?

Yes, there is one. No, there isn’t. Is. Isn’t.

If you were aware of that controversy you might wonder whatever happened to it. Was anything about the mysterious G-spot ever resolved?

For all intents and purposes, after a flurry of attention in the 1980s, the G-spot seemed to go underground for a decade or two, but lately, with the advent of newfangled imaging devices, the search for the G-spot has resurrected once again. So, in case you’ve been wondering, let us bring you up to date on this mysterious region.

The G-spot is defined (and yes, there is a definition) as an erogenous area about the size of a nickel located 2 to 3 inches inside the front wall of a woman’s vagina.

The name comes from the German gynecologist Ernst Gräfenberg, who first wrote about its existence in 1950. But a mysterious pleasure center in roughly the same place had also been mentioned in ancient Indian texts and by Regnier de Graaf, a Dutch physician, in 1672, who wrote that secretions from this area “lubricate their sexual parts in agreeable fashion during coitus.”

But it was the publication of The G-Spot and Other Discoveries about Human Sexuality in the 1980s that ignited a frenzy. Couples contorted themselves into pretzels seeking the elusive mind-blowing orgasms that accompanied just the right stimulation. (Leaving many women feeling inadequate and their partners frustrated, I’m sure.) Researchers, too, overheated their Bunsen burners trying to find the darned thing.

Then, without further fuel to fan the fire, the short attention span of popular culture wandered, and interest in the G-spot waned.

In 2008, however, Italian researchers using new ultrasound technology discovered a thickened area on the front vaginal wall of about half of 20 women. Women with this thickened tissue were more likely to experience vaginal orgasms. In 2010, a group of British researchers asked 90 pairs of twins if they had a “so called G-spot, a small area the size of a 20p coin on the front wall of your vagina that is sensitive to deep pressure?”

Unsurprisingly, given the subjective nature of that question, the results from the British study were ambiguous and were challenged by other scientists. The following month French researchers, askance at the sloppy work from the boys across the channel, declared that 56 percent of women did indeed have “un point G.”

Physiologically, a G-spot has not been definitively identified by gynecologists, nor in dissections nor consistently in ultrasounds. So the mystery remains, according to urologist Dr. Amichai Kilchevsky, who led an extensive review of all research on the issue. “Without a doubt, a discreet anatomic entity call the G-spot does not exist,” says Dr. Kilchevsky.

Yet, women consistently report that stimulating the front of the vaginal wall produces a deep, pleasurable orgasm. “…it has been pretty widely accepted that many women find it pleasurable, if not orgasmic, to be stimulated on the front wall of the vagina," said Debby Herbenick, researcher at Indiana University and author of Because It Feels Good.

According to Australian researcher Dr. Helen O’Connell, the clitoris, urethra, and vagina all work together during sexual stimulation, creating a “clitoral complex.” Since the urethra lies along the outside of the vagina and the clitoris has deep “roots” within the vaginal walls it’s no stretch to imagine that all the parts work together during sex.

Some doctors compare the G-spot controversy to obsession over penis size—much ado about nothing. Lots of women don’t orgasm with vaginal penetration alone; indeed, most of us need both vaginal and clitoral stimulation to orgasm. So, if “we don't even have orgasm all figured out yet, I don't know why we would expect to have the G-spot figured out,” Herbenick said in an article on Netdoctor.

Because of its approximate location, the G-spot is devilishly hard to reach, especially in the standard missionary position. However, if you’d like to spice up your bedtime routine with a little research of your own, try sitting astride your partner, on a sturdy chair or firm surface. Lean backward so the penis has a better chance of connecting with the front of the vagina.

If this sounds too acrobatic for a fun Friday night, you can always fall back on the trusty index finger. Lie on your back while your partner inserts his finger, using a “come hither” motion to stimulate front of the vagina. Or try a toy. Special G-spot vibrators are available that are longer with a kink at the end. Results are still mixed, so focus on the exploration, not a specific result.

And remember to be well-lubricated and relaxed. Light a few candles and some incense. Research has never been so fun.

New Friends, New Resources

A wonderful and unexpected benefit of starting MiddlesexMD has been meeting other women and men who are like-minded, who see the value in—have a passion for—supporting sexuality throughout our lives. As we’ve gone to conferences and association events, I’ve been able to talk to doctors, nurse practitioners, and therapists who are eager to spread the word and join forces.

I’ve talked before about how the mind is as important for women as the body; that’s what makes the Basson model of female sexual response so helpful for my conversations with patients. Our need to address the emotional as well as physical aspects of sexuality made one of our encounters especially fortuitous: We met Mary Jo Rapini, a Texas-based psychotherapist who specializes in intimacy, sex, and relationships.

As a psychotherapist, Mary Jo can help us to round out the resources we offer you—so we’re thrilled that she’s offered her expertise to MiddlesexMD! Mary Jo has a private practice, but also publishes and speaks in a variety of places; you’ll learn more over the next several months. Plus we’ll interview her from time to time on topics of particular interest to us as midlife women.

To give you an idea of what’s in store, here is an excerpt from Mary Jo’s recent post, “Women Need Time to Get Their Sexy On,” in YourTango (read the whole article online):

“Body image is so highly correlated with women’s sexuality that in a recent study reported in the Journal of Sex Research, Dr. Patricia Barthalow Koch PhD discovered that body image was one of the top reasons women don’t want to have sex. Men may have difficulty understanding this because many of them tell their wives every day how beautiful she looks only to realize their wife still doesn’t want to have sex. The husbands may not understand that although their intentions are good, their wife doesn’t derive her body image by what he says. It may help and reassure his wife, but more helpful is if she believes that she is beautiful and desirable. In other words, if she beats herself up, or is critical in regards to her looks when she compares herself to others no matter what her husband tells her, it falls on deaf ears.”

Yes! Precisely. I hear evidence of this same issue. And remember our discussions of erotica? How it’s different for us than for men? Mary Jo goes on to talk about the same issues:

“Women need different stimuli to turn them on than men. We don’t get excited when we see a naked man. In fact, most women prefer a man with shorts on to a man in the buff…. Your sex text may not do it for us, but if we catch a glance at your jaw while you are drinking from a water fountain in the right lighting, we may feel a sexual impulse. Women don’t talk to you about this, because we know you won’t understand. Women are also somewhat reticent about telling you what turns them on, because it is so different than what turns men on, or what media believes should turn them on.”

You can see why I’m glad to have Mary Jo’s perspective and expertise with us for our exploration. Watch the blog and our Facebook page for more results of our work together. We can’t wait!

December 24, 2010

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Under the Covers ›  


With Gratitude, Happy Holidays!

I’m sure I’m not the only one who gets sentimental during the holidays. As my family gathers in a home that looks better than usual, preparing gifts and eating more-than-usually festive food, I can’t help but feel fortunate.

Part of what I’m grateful for is the response to MiddlesexMD, which we launched at the beginning of the year. I’ve had a few years of experience focusing on mid-life women in my medical practice, including the satisfaction of hearing from women who’ve gotten their sex lives back. Through MiddlesexMD I’ve been able to have a broader conversation with more women and more health care practitioners.

There have been very specific comments from people—both women and their partners—who’ve found success with information or products they’ve found on our site. Health care practitioners I’ve met at conferences have endorsed what we’re doing with some variation of “This is exactly what I’ve been looking for to help my patients!”

In the midst of this holiday season, then, I’d like to say thank you—to the readers of this blog, our correspondents and customers, my health care colleagues, and the MiddlesexMD team. I wish for all of you a very happy holiday season—full of joy and leisure and seasoned with romance!

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