December 13, 2010

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communication ›   Under the Covers ›  


Another Way to Stay in Touch

We love hearing from our readers and our customers. We’re thrilled when we hear from someone who’s gotten unstuck in her sex life because of information or products we’ve been able to supply.

Two recent messages, for example: A husband e-mailed us in happy disbelief that his wife’s use of vaginal dilators had enabled them to have comfortable sex for the first time in two years. A woman e-mailed to say that Yes vaginal moisturizer had eliminated her pain.

On a lighter note, we got a lot of response on Facebook when we shared—just in time for Thanksgiving—research that proved the scent of pumpkin pie is arousing—especially for men! A few extra pies were baked, we’re guessing….

We keep looking for ways to continue the conversation. We’ve started an e-mail newsletter so a couple of times a month we can highlight recent research or discussions, tell you about new products, and report on other events we’re involved in. We’ll even, from time to time, offer special gifts to folks who subscribe to the newsletter

Even if you’re already a blog subscriber, we invite you to consider signing up for the newsletter or “liking” us on Facebook. Hey, consider it a practice of mindfulness: We know that the more we think about sex, the more sex we have!

The Third Component of Great Sex: Deep Sexual and Erotic Intimacy

What's the difference between "connection" (number two of the "eight components of optimal sexuality") and "deep sexual and erotic intimacy" (number three)? That stumped me for a bit while I was digesting the study published last year in The Canadian Journal of Human Sexuality.

Then I read this quote from one of the study’s participants, describing a type of intimacy that goes beyond intense connection in the moment: “It’s part of the way you act with each other long before you’re actually engaged in any kind of, you know, technical sex.”

I like that. I think that “the way you act with each other” before, after, and during “technical sex” is essential to deep erotic and emotional intimacy. Trust, respect, and real admiration and acceptance build the foundation for a truly intimate relationship. These are things that take time, that come with knowing each other in a profound way.

And, in my experience, you can tell if a couple has this kind of intimacy just by observing the way they interact at the grocery store or a dinner party. Do they laugh at each other’s jokes? Do they exchange quick touches and knowing glances? Do they refrain from criticizing each others’ tastes in breakfast cereal?

According to study participants, a deep sense of caring for one’s partner is a key characteristic of sexual intimacy. One woman mentioned that her need to feel solicitude and concern had become more important to her with age: “I don’t know that I’m capable of having great sex anymore without really caring about a partner.”

The study’s authors noted that “almost every participant identified a deep and penetrating sense of trust as characteristic of the intimacy that was part of great sex for them.” They needed to trust that their partners cared for them and that the relationship was secure.

This kind of trust and intimacy doesn’t just happen. It takes time and openness and communication. Especially at midlife, when our bodies and needs are changing, it’s important for partners to talk with each other, to stay up-to-date on feelings and desires. Honest and caring talk about sex can be erotic in itself, and can go a long way toward creating and maintaining the deep intimacy that makes for sex that is “better than good.”

More on this next week, when we look at component number four: Extraordinary Communication!

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.

Q: Would vaginal dilators help me with painful penetration?

Vaginal dilators really do work to increase vaginal caliber--the size of the opening. If you're having your first sexual encounters, have an exam by your healthcare provider to rule out other causes: there may be an issue with the hymen, for example, that would have a different solution.

But for women who've been sexually active, dilators can make a world of difference. I had an e-mail a couple of weeks ago from a woman who hadn't been able to have intercourse for two years. After using vaginal dilators for a month, she was able to have pain-free sex!

Dilators come in graduated sizes; the smallest is only a half-inch in diameter. They are used with a lubricant daily. When you're comfortable with one size, you progress to the next-larger dilator until you've achieved the caliber--the opening size--that works for you and your partner.

Vaginal caliber is only one element of our sexuality, of course. I encourage women to think about the whole picture. But if a narrowing vagina is a problem for you, vaginal dilators really can help.

Warming Up to Foreplay

I’m a recreational runner, and before a run, I always spend a few minutes warming up. I’ll run in place and do some stretches, especially of my calves and ankles. Experts no longer say this is a must, but I do it anyway because I know that as I’ve grown older, I have tighter muscles and less range of motion in my joints. And I’ve learned that if I exercise and end up hurting, I’ll be more likely to postpone my next outing.

This cycle can also be true of sex. If you rush past the warm-up—foreplay—you may not have enough lubrication to make penetration comfortable. If sex hurts, you’re less likely to initiate it or to respond to your partner. The more time that passes without having sex, the more difficult it is.

Many couples have a long habit of foreplay, but If the women I talk to are representative of the larger population (and I believe they are), men don’t always get the connection. They are happy to skip the foreplay and sprint to the finish line. Early in the relationship, that might work even for women, who are more sexually complex than men, because excitement is high all the way around and it’s easier to get aroused. It might even fly during the “thirsty thirties,” when women’s sexuality peaks.

But during menopause and after, hormones work against us. Estrogen declines, vaginal tissues become thinner and more fragile, and circulation to those tissues decreases. The less stimulation your vagina receives—from sex with a partner or your own self-care—the faster those changes happen.We’re not kidding when we say, “use it or lose it!”

So after menopause, we need more to warm up. More real intimacy, more talk, more titillation. In short, more time.  The stakes are higher now. If we don’t warm up, it hurts. If it hurts, we don’t want it. If we avoid it for too long, it’s more and more difficult to have it. If any of this sounds familiar, it’s probably time to talk about it.

Because a little foreplay has gone a long way in the past, your partner might be puzzled when you suggest your lovemaking include more foreplay. He might worry he’s losing his sexual prowess. This is a great opportunity to explain how changing hormones affect your response to sex. If there’s something you’ve secretly been longing to suggest to him lo these many years, you can slip that into the discussion, too. It’s never too late for your partner to learn, and telling him what you need and why is a great first step.

How about you? Have you been able to change the patterns of sex with your partner? How did you approach it? How did your partner respond? We’d love to hear!

October 18, 2010

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menopause ›   NAMS ›   sexuality ›   Under the Covers ›  


MiddlesexMD Online Community Roundup

Now that our new site has been up for a while, we've met and made friends with others in online communities serving midlife women and sharing information about sexual health. We'd love for you to meet some of our new friends:

The amazing women at Vibrant Nation invited me to participate in their -- really very vibrant -- community. It's a great place to explore and share life with others our age. Four of our posts made the top 10 in August and September!

Liz from Flashfree (Not Your Mamas Menopause) asked for a guest post on her blog, where she writes about the physical, emotional, and societal issues that surround midlife and menopause. I was happy to oblige.

I had a great time discussing sex at menopause on the Voice of the Nation show "Sex with Jaiya", who was very interested in hearing about how we can adjust our ideas about sexuality to meet the changes we experience as we age.

Melinda Blau's MotherU was a marvelous blog she keeps with her daughter, Jennifer Blau Martin. Melinda is a bestselling author, and a brilliant blogger who does a great job of including as many voices as she can on her comforting and informative blog. She asked to run our recent contemplation of new grandmotherhood.

And we love Owning Pink, an online community that endorses and celebrates living full and authentic lives. I've joined the Pink Posse to talk about Owning Sexuality. I swear it's not just so that I can say that I've joined the Pink Posse, though that's a pretty good reason to join up.

In the off-line community, we've just come back from participating at The North American Menopause Society Annual Meeting in Chicago and the Nurse Practitioners in Women's Health Women's HealthCare Conference in California. We made lots of new friends--and were exhilarated by the response! Whew! Now to catch our collective breath...

Q: How can I increase sensation and more readily orgasm?

There is no doubt that the ability to achieve an orgasm becomes more difficult as we age, and the orgasm itself is often briefer and less intense. As we age, we need more time for every step of the process, starting with foreplay. Sometimes our partners need to hear a clear message about what's changing for us! We hope our website can make it easier to have those discussions with a partner.

Using a warming lube, like Oceanus G Stimulating or Sliquid Organics Stimulating O Gel, can improve sensation for some women. Warming lubes include a minty or peppery ingredient, which increases circulation and sensation in genital tissues.

You mention occasional orgasm success with a vibrator. Not all vibrators are alike: Some don't provide the intensity of vibration that our tissues need in midlife. We offer vibrators by Emotional Bliss that are more powerful than average, designed for those who specifically need more stimulation, more intensity. I’ve seen some amazing results with these in women who previously were unable to have an orgasm because of neurologic diseases or medications that are known to interfere with orgasm.

You might also talk to your health care provider to see whether vaginal (or localized) estrogen is a good option for you. Lack of estrogen to vaginal tissues results in a decrease in circulation, which leads to less sensation, which is why you may not sense penetration as you did before.

Do talk to your partner and explore your options. Sexual satisfaction comes in many forms, but if you're missing orgasms, there's no reason to leave them behind.

Can We Talk? I’m Not Sure.

Maybe I was naïve. We ran into some issues with the launch of MiddlesexMD.com earlier this year: We couldn’t advertise on a popular social networking site. An article we submitted was rejected because of subject matter. We were “ineligible” for a medical site designation.

And I took all that in stride, with some disappointment, as an entrepreneur, and some concern, as a physician trying to get the word out to women that sex is good for you and still possible and pleasurable, well beyond menopause. But I’m a parent, too, and I understand that there’s adult content that can’t just go everywhere.

But in the last week I saw a couple of articles (one in the New York Times) about Zestra and the walls its makers were hitting in trying to advertise. If you’ve missed the story, a commercial for Zestra Essential Arousal Oils was turned down by TV networks, cable stations, radio stations, and web sites. When it was accepted at all, it was slated to run in the middle of the night. Rachel Braun Scherl, the president of the company that makes Zestra, says, “When it comes to talking about the realities of women’s lives, you always have some woman running in the field…. There’s a double standard when it comes to society’s comfort level with female sexual health and enjoyment.”

As evidence, Rachel points to the advertising for Viagra and Cialis. And that’s when I start to think I may have been naïve. I remember the first time Bob Dole came on my television, during prime time, when my daughters were in middle school and still watching TV with me. It was a little awkward, maybe, to explain to them what “erectile dysfunction” was, exactly. Now they’re old enough to snicker with me (in a compassionate way—I am a doctor) when we hear “in the event of an erection lasting more than four hours, seek medical attention.”

So this gets me thinking. Why can we be so public about an aid to a man’s sexual satisfaction, but not aids to a woman’s? Is it because Viagra and Cialis are prescription products for a condition that’s been named a medical problem? In the case of erectile dysfunction, have we successfully separated the erection from sexuality? Because women’s arousal and satisfaction are more complex (remember why we love Rosemary?), is it too difficult to make that same separation? Or is there really still a double standard, with men’s sexual satisfaction ranking higher then women’s?

I’ll keep thinking. And, I’m sure, gathering anecdotal evidence on both sides of my questions. I’d love for you to join the conversation.

Missing Orgasm: Is It Me or My SSRI?

Are the medications you're on behind your loss of interest in sex? Are they making it more difficult for you to reach orgasm? These are tough questions. On one hand, the answer is almost always "yes": So many of the medications we take--including pain meds and sleeping aids--list lower libido as a potential side effect. On the other hand, the answer is also usually "no": In my experience, the meds aren't usually the primary cause.

With one exception. If a patient reports a notable change in her ability to reach orgasm and is taking medication for depression or anxiety, I ask if she's on an SSRI.

The most commonly used antidepressants today, SSRIs--selective serotonin reuptake inhibitors (I know it's a tongue twister)--are very effective in treating depression and anxiety disorders. Unfortunately, they also tend to dampen a woman's ability to experience orgasm.

SSRIs--some of the most commonly prescribed are Prozac (fluoxetine), Paxil (paroxetine), and Zoloft (sertraline)--work by raising levels of serotonin in the brain, enhancing neurotransmission and improving mood. The "selective" part of the name is because SSRIs affect only one type of neurotransmitter--serotonin. But higher serotonin can lead to lower libido--and missing orgasms.

Of course, depression and anxiety all by themselves often lead to reduced interest in sex, so it can be hard to tease out cause and effect. But when a patient tells me she has lost desire or orgasmic function since beginning antidepressants, I often suggest that she consider switching medications.

Other types of antidepressants, like Wellbutrin (buproprion), act on dopamine neurotransmitters and typically have fewer adverse sexual side effects. In fact, studies suggest that increased levels of dopamine in the brain may actually facilitate sexual functions including libido and orgasm.

Sometimes bupropion is prescribed in addition to an SSRI, sometimes as a replacement. Doctors can often try different combinations and dosages until they find the prescription that treats the depression without robbing patients of their orgasms.

If switching isn't an option or if changing the prescription doesn't do the trick, there are other options. Even on SSRIs, a sluggish libido or elusive orgasm will respond to increased lubrication and stimulation.

Dealing with depression is hard. We don't have to make it harder by accepting the loss of an important part of ourselves. If you've struggled with the trade-offs, let us know how it's worked out for you.

Q: I quit the pill and tested mid-menopause in one month; now sex hurts. Suggestions?

Isn’t it amazing how quickly things can change? You say you were tested as being mid-menopause. Blood work is accurate at assessing ovarian function on the day you're tested, but it is miserable in predicting what may happen in the next weeks or months. An FSH level may come back 40 (suggesting menopause) on one day, but you may ovulate 6 weeks from now at have an FSH at 8. It's really only over time that you really can better understand if this is the ‘new norm’ or transient. Perimenopause is known to have fluctuating symptoms; once in menopause, most women's symptoms are more predictable.

To make sex comfortable again, I would start with a lubricant. I would try a water-based lube like Carrageenan or Yes. If using a lube makes you comfortable and doesn't irritate the area, that can be a great, simple solution for now.

A warming lube can add some additional sensation for arousal and make orgasm somewhat stronger. Try Oceanus G Stimulating or Sliquid Sensations. Occasionally the warming lubes can be irritating if the area is sensitive, which is why I'd start with a non-stimulating water-based lube; then test a small amount of the warming lube to see if it works for you!

Good luck! I know you can have satisfying sex again.