How We Get Turned On

The Female Sexual Response Cycle

As we’ve said (many times) before, our sexual responses are complicated and unpredictable. And this becomes especially true once we’ve embarked upon this menopausal transition. That doesn’t mean we can’t respond sexually anymore, just that we respond differently from men and differently even from the way we did before.

Way back in the 1960s, Masters and Johnson, the groundbreaking sexologists, developed a graph of the sexual response cycle. It was a simple, linear depiction that purported to track both men and women from arousal to afterglow in four stages—arousal, plateau, orgasm, and resolution. Sort of like a visual depiction of the wham-bam-thank-you-ma’am version of sex that women used to think was normal.

It did not contain a lot of room for nuance.

Fortunately, concepts about how we respond sexually have evolved over the years. Lately, Rosemary Basson, professor of psychiatry at the University of British Columbia, proposed another model of how women, specifically, experience sex. Guess what? It’s different from men. Her graph is circular. It includes elements that previously weren’t linked to sex, like relationship satisfaction and self-image, and our previous sexual experiences. It leaves room for skipped steps and a non-linear response to sex. This woman gets us.

Take feeling desire, for example. Basson’s model doesn’t get all hung up on desire. You may not feel spontaneous desire—the old “horny” thing—the way you used to. Or maybe you’ve never felt horny. According to a 1999 study from the University of Chicago, fully one-third of women never feel desire. “[Women] may move from sexual arousal to orgasm and satisfaction without experiencing sexual desire, or they can experience desire, arousal, and satisfaction but not orgasm,” according to this article.

You may not feel desire until you’ve begun to have sex; you might not feel desire even then. You might not feel desire even if you orgasm.

Likewise, for a lot of us, sexual satisfaction doesn’t even depend on having an orgasm, necessarily. We may have lovely, satisfying sex because it satisfies our partner and affirms the relationship and enhances our feeling of intimacy. Or, we may engage in sex for negative reasons, such as not wanting to lose a partner or avoiding the unpleasantness of turning him down.

Basically, Basson’s work tells us that however we experience sex that works for us and our partner is good sex. We may not “feel like” sex (experience desire), but once we get into it, desire might come tripping along like a puppy on a leash. Or, it might not, but the sex might be good anyway.

According to the literature, the sex that seems to work best for most couples is light-hearted, flirty, playful sex. It isn’t rushed. It has nothing to prove. It’s a mature, evolved celebration of the fact we’re still here, still loving each other. It’s the kind of sex worth working for.

Couple in kitchenSo, let’s give ourselves a break. If we’ve been honest with ourselves, our sexual response very often depends on stimuli that has little to do with sex—how safe and happy we are in our relationship; how long we’ve been in the relationship; how we feel about ourselves (confident, sexy, desirable; or fatigued, stressed, distracted); whether sex has been painful (it’s hard to look forward to an experience that’s associated with pain).

The most important thing that’s necessary for sexual satisfaction in your relationship is the willingness to pursue it in whatever way works for you.

Oh, and the more sex you have, the more you want it. There are lots of ways to make sex comfortable after menopause: That’s what this website is all about; lube up and laissez le bons temps rouler.

 

 

Q: Does the Intensity’s vibration help to strengthen the pelvic floor?

The Intensity Pelvic Tone Vibrator works in two ways: It has electrodes that stimulate the muscles of the pelvic floor, causing them to contract and therefore strengthen. The vibration feature of the Intensity, which you can control separately, improves pelvic floor muscle tone the same way any vibrator does: They all help the user to experience orgasm, which is intense contractions of the pelvic floor. Those contractions, whether from the electric pulses or orgasm, improve muscle tone, just like flexing your bicep does. The contractions also increase blood supply to the pelvis, which improves function and sensation, too.

Yes, orgasm is good for muscle tone! And improved muscle tone can strengthen future orgasms, as well as holding organs in place and preventing or minimizing incontinence. I guess I’d call that a virtuous cycle.

Q: Are there non-synthetic hormone replacement options?

You asked. Dr. Barb answered.There are plenty of bioidentical pharmaceutical hormone options to treat menopausal symptoms. Over 90 percent of my hormone therapy patients use these, and most physicians who treat menopause are familiar with the options. There are brand name and generic products available; to list some of them: Estrace, Vivelle, Minivelle, transdermal estradiol, Prometrium, micronized progesterone.

You also mention weight gain. I hope you know you’re not alone! We had a series on this topic this summer that may be of interest to you: an overview of the reality, how you can respond with diet alterations, and how exercise can play a part.

If you need a provider who focuses on menopausal treatments you can find one on the NAMS website (North American Menopause Society) at this link. Enter your zip code and a list of nearby providers will be listed.

Good luck!

New Research on Heart Attacks and Sex

Among other things, sex is a nice aerobic workout. You breathe hard; your heart rate goes up, as does your metabolic rate. You burn calories. (Yay!)

Therein lies the rub for us older folks.

Isn’t the stress on the cardiovascular system dangerous for anyone with a heart condition? Especially if he or she doesn’t know about it? Or, even when the doctor gives you the green light to have sex, the specter of a sudden attack always looms in the background.

"I think it's important to healthy relationships to have this anxiety lifted," said Dr. Michael Ackerman, professor of medicine at Mayo Clinic. “[People] always ask about exercise and how active they can become,” he said in this article. “They almost never ask directly about sex,” but, once it’s mentioned, he said, ”the floodgates open.”

Now, a large and robust study provides the most detailed picture we’ve even had of the actual numbers of people who suffered a fatal heart attack during sex. Researchers examined lifetime medical records from 4,557 people in Portland, Oregon, who died of a sudden cardiac arrest from 2002 to 2015.

Of the 4557, the number of people who died of a heart attack during sex or within an hour after?

34.

That’s it. Thirty-four people ranging in age from 37 to 83. Of that number, 32 were men. Thus, the risk of having a heart attack during sex in men is 1 percent, while for women, it’s .1 percent. While doctors always knew the risk of heart attack was slim, now that the risk is quantified, even researchers were taken aback. “I’m a little surprised at the really tiny number,” said Dr. Sumeet Chugh, senior author of the study and a professor of medicine at Cedars-Sinai Heart Institute in Los Angeles.

It goes without saying to follow your own doctor’s instructions for activity if you have a heart condition. But if you’re given the “all clear” for sexual activity, I hope these numbers put your mind at ease. No need to abstain from one of life’s sweetest pleasures.

“[This is] a wonderful answer for those who love sex,” said Dr. Ackerman. And, I might add, for those who recognize the link between sexual health and overall good health.

 

 

Sex and Your Hysterectomy: The Options

As I mentioned in the last post on this topic, even after you’ve decided to have a hysterectomy, a few critical questions remain. Time for a sit-down with your surgeon to hash them out.

First: How will he or she perform the procedure. There are three basic surgical options. The type of procedure your doctor chooses will affect the speed of your recovery, how long you’ll be in the hospital, and how much pain you’ll experience.  

  • Abdominal hysterectomy involves removing the uterus through an incision in the abdomen, usually along the bikini line. This route involves more risk, more pain, and a longer recovery period. Depending on your unique situation, this may be the best (or only) approach, but studies consistently show that, in most cases, the following two options are preferable.
  • Laparoscopic hysterectomy involves using tiny cameras and surgical tools—sometimes operated by a robot—inserted through small abdominal incisions, either to do the hysterectomy entirely or to assist in a vaginal procedure. This is less invasive with good outcomes.
  • Vaginal hysterectomy is just what it sounds like—the uterus is withdrawn through the vagina without requiring an incision. Generally, this procedure was found to involve fewest complications, to take less time to perform, and to offer the best outcome. Some factors, such as the size of the uterus or the shape of the pelvis, might prohibit a vaginal hysterectomy, but overall, this is the best choice.

You should discuss what procedure your surgeon recommends and why. The quality and speed of your recovery rests in his or her hands.

The second topic to thoroughly discuss with your doctor is what, exactly, he or she is taking out. Here are the three umbrella categories of hysterectomy.

Hysterectomy

Hysterectomy is the removal of your uterus and the cervix, which is the organ at the top of the vagina. A lot of discussion and very few facts surrounds the pros and cons of leaving the cervix intact. Unless there’s a problem with the cervix itself, there’s no biological need to take it out—or to leave it in. The preponderance of evidence suggests that the cervix has little to do with sex, and removing it doesn’t seem to change sensation or to affect orgasm.

Removing the cervix, however, can change the vagina: It can become shorter, although rarely enough to compromise sex; some nerves might also be affected, which could make the top of your vagina more sensitive, and not in a good way. But the vagina, as we know, is a very stretchy and forgiving organ, so with the use of dilators (and gentle, consistent sex) the situation can be remedied.

Often, the cervix is removed prophylactically, to avoid a small but real cancer risk. Without a cervix, there’s no longer a risk, ergo, no more pap tests. That’s one point in its favor.

Supracervical Hysterectomy

In the supracervical hysterectomy procedure, only the uterus is removed, leaving the cervix, fallopian tubes, and ovaries intact. In this case, you probably won’t experience much difference in your sexual activity unless you were accustomed to deep-muscle uterine contractions with orgasm. No uterus; no more muscular contractions. You might notice other changes, however, that we’ll discuss in the next post in this series.

Hysterectomy with Bi- (or Uni-) Lateral Salpingo-Oopherectomy

Hysterectomy with bi- (or uni-) lateral salpingo-oopherectomy. Yes, it’s unpronounceable. This is the removal of one or both ovaries and the fallopian tubes along with the uterus. Unless you’re well into menopause, this procedure can put a woman in a hormonal tailspin.

The ovaries are the seat of much of testosterone production (it’s also produced by adrenals) and estrogen production—all the good stuff that keeps the sexual apparatus and our moods humming nicely along. Removing them while they’re still functioning puts a woman into immediate and sometimes intense menopause. It’s called “surgically induced menopause.” For that reason, ovaries are left intact, if possible, especially in younger women.

The decision can be complicated, however. The ovaries themselves can be diseased. Also, some women carry a genetic trait called the BRCA mutation. They are at a much higher risk for breast and ovarian cancer. While breast cancers are often identified at early stages, no screening or early-stage detection exists for ovarian cancer. It’s usually discovered later, when it’s very hard to treat. For women without that genetic trait, the risk of ovarian cancer is low, but not zero.

When menopause is surgically induced, your sex life (among other things) is likely to be seriously impacted just as it is in menopause. You should prepare for low libido, a possible decrease in arousal, dry vagina—all the issues we cover so repeatedly here.

I’d strongly advise you to line up resources ahead of time. Make an appointment with a gynecologist who specializes in menopausal issues. You might be a good candidate for estrogen and/or testosterone therapy. Stock up on lubes and moisturizers. Fire up the vibrator. The hormonal transition could be rocky, but with support and medical oversight, you’ll get through it. Sex (and life) will be good again. Promise.

A lot of issues and options are involved with the decision to have a hysterectomy (beginning with the question of having one at all). Believe me, you want to understand the process, your options, and the possible outcomes. When it comes to this part of your body and your being, you want to know what’s going to happen and to minimize the surprise factor.

 

 

 

Sex and Your Hysterectomy: A Primer

I’m just gonna say it: the best time to get information about sex after a hysterectomy is before the hysterectomy ever happens.

When a patient come to me with sexual issues after having had a hysterectomy, and she is unclear about what kind of hysterectomy she actually received—what organs were removed or whether she had a laparoscopic or a vaginal procedure, for example—this indicates to me that she may not have sought or received the information she needed in order to make an informed decision.

Whether to have a hysterectomy is a loaded topic these days, so let’s just dive in and get the facts out of the way, shall we?

Hysterectomy is the second most common surgical procedure performed on women after caesarian section.  Almost 12 percent of women between 40 and 44 have had one. That number rises to 30 percent by the time you’re 60. About 600,000 procedures are performed every year in the US—the highest rate in the world, although other developed countries also do a lot of hysterectomies.

Most hysterectomies are performed for such benign but bothersome conditions as fibroid growths, endometriosis, heavy bleeding, and vaginal prolapse. Only about 10 percent are done for truly life-threatening conditions such as cancer or a uterine rupture during childbirth.

It’s almost like having a hysterectomy has become a normalized part of growing older as a woman. You get your hair colored, and you have a hysterectomy. That’s just how it goes.

Recently, however, women’s health organizations and other health professionals—as well as women themselves—have been questioning that inevitability and pushing for less radical treatments for benign conditions. These include less invasive treatments, such as having a progestin IUD placed or endometrial ablation for heavy bleeding or uterine artery embolectomy treatments for fibroids. Still, hysterectomy remains the most common go-to for a host of “female troubles.”

Like any surgical procedure, a hysterectomy involves weighing risks and benefits. These are dependent on factors such as age, childbirth history, the size and shape of the uterus, among other considerations.

For example, it might be better for a younger woman with a benign and treatable condition to first try the alternatives to the permanent removal of her uterus because her reproductive organs are still fertile and hormone-producing. Even a woman in perimenopause is still producing hormones with all their good protective benefits to vaginal tissue, heart, and bone.

A post-menopausal woman with an unpleasant uterine prolapse, on the other hand, might be a very good candidate for hysterectomy. This patient’s hormone production has virtually ended and other treatment options aren’t permanent or also involve a surgical procedure.

Sometimes, however, when a woman’s quality of life is so compromised, when she’s in enough pain or bleeding so erratically or profusely, she may be willing to do anything to make it stop. A hysterectomy will make it stop and will often improve both sex and quality of life. But a frank patient/doctor discussion is still critical—so she understands her options and, insofar as possible, what the outcome will be.

So—there are options for treatments of benign conditions such as fibroids or endometriosis. Hysterectomy is invasive and permanent, so it makes sense to explore other options first. But if a hysterectomy seems to be the best approach, you then need to know about the different types of hysterectomy and their outcomes.

This is important, ladies, because how quickly you recover and the effect on your sex life has everything to do with the type of surgery you have and what organs are removed.  

We’ll discuss this in a post next week.

Why You Need Both a Gynecologist and a General Practitioner

Regular or decaf. White wine or red. Chocolate or vanilla.

Choices abound. Some are inconsequential—the whim of the moment. Others matter, like your choice of health care provider. I’d like to make the case that, although you may be well past childbearing years, you haven’t outgrown being a woman. Ergo, you still have very unique and specific needs that are best served by a specialist with training and experience in all things feminine.

Most gynecologists see an abrupt migration of their older patients to internal medicine or family practice providers. “…between ages 45 and 55, you start to see a very sharp decline in the number of encounters between women and their ob/gyn--and a mirror-image rise in visits to internal medicine,” says Dr. Michael Zinaman, director of reproductive endocrinology at Loyola University Medical Center in this article.

Not for one moment am I suggesting that this is a bad thing. General practitioners take a broad and thorough approach to patient care. In a typical exam on an older woman, an internist would screen for diabetes, colon and other common cancers, osteoporosis, high blood pressure and cholesterol, anemia and other blood disorders—basically, the whole enchilada. Since heart disease is the #1 killer for women, it’s a good idea to have this type of broad screening every year.

Internists also counsel with patients about lifestyle issues, such as smoking or weight control, diet or exercise (which I also do regularly). And they might refer and coordinate a patient’s care with various specialists.

So, why might a woman who no longer needs reproductive care and who may or may not even have her reproductive organs continue to see a gynecologist? Well, for all the stuff we talk about on this website, for starters.

Older women have specific needs and vulnerabilities for which gynecologists have deep and specific training and experience. The incidence of breast and ovarian cancers increase with age, for example. And although internists may do pelvic exams (and note that “may”; even when, after age 65, we no longer need a pap smear, we still need regular pelvic exams) and order mammograms, gynecologist have years of practice in detection and treatment.

Then, there are all those everyday annoyances of menopause and an aging reproductive system—pelvic organ prolapse, incontinence, hormonal disruption, and all those vexing sexual changes we address here on MiddlesexMD. When it comes to treating these quotidian challenges to health and well-being, gynecologists are simply the specialist. We’re more likely to know about new treatments and medications; we’re more likely to catch anomalies; we’re very attuned to kinds of changes that can signal something serious.

But the bottom line? This isn’t one of those either/or decisions. You can choose between a chocolate sundae and a frozen yogurt, but the choice isn’t between a gynecologist and a general practitioner.

You need both. And both healthcare providers need to be working together for you. “A collaborative approach would be very good,” said Dr. C. Anderson Hedberg, head of general internal medicine at Rush-Presbyterian-St. Luke’s Medical Center.

In one study comparing the type of screenings women tended to receive from primary care doctors as opposed to gynecologists, researchers found that gynecologists were more likely to screen for cervical and breast cancers, and osteoporosis, while primary care doctors were more likely to test for colon cancer, high cholesterol, and diabetes.

I’m thinking you wouldn’t want to miss out on any of this fun stuff, and you sure want to know early on about issues or warning signs. But in the end, you make the judgment calls about your health. You decide what doctor to see and how often and whether or not to follow medical advice. That’s as it should be.

Having the right medical team on your side simply gives you the ability to make the best, most informed choices.

Q: Can I believe what I read about a product for vaginal tightening?

You asked. Dr. Barb answered.I’m not sure which "tightening product" you’ve seen. The only way to tighten the vagina is to tighten the surrounding muscles. Kegel exercises (we give instructions on our website) target the muscles of the pelvic floor. And many women find that exercise tools (like vaginal weights or a barbell) helps them be sure they’re flexing the right muscles. I also recommend the Intensity Pelvic Tone Vibrator, which uses a combination of electrical pulses and vibration to build pelvic tone.

Q: What do you think about sexual arousal gels or creams?


You asked. Dr. Barb answered.The sexual arousal creams and gels are effective, and beneficial to most women who use them. Like our category of “warming lubricants and oils,” they typically use an ingredient like menthol, mint, or pepper to stimulate circulation, which increases responsiveness during intimacy. Read the instructions for the product you intend to use, to be sure you understand whether it’s for internal or only external use; lubricants are generally safe for internal tissues.

Arousal and warming products have the potential to cause some irritation for those women with significant atrophy, or thinning of the vulvovaginal tissues. I recommend applying a small amount to the genitals in advance of sex to make sure it’s comfortable and pleasurable.

Q: What can you tell me about Intrarosa?

You asked. Dr. Barb answered.Intrarosa is a new product for treating vaginal atrophy, approved by the FDA in November of 2016. It will be available by prescription only; it’s not yet in pharmacies but is likely to be later in 2017. The clinical trials for Intrarosa are favorable for treating vaginal atrophy, or genitourinary syndrome of menopause causing painful intercourse. It is an adrenal hormone, prasterone (dehydroepiandrosterone), formulated as a once-a-day vaginal insert.

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