MiddlesexMD

A Vibrator Designed for Serious Waves

When it comes to your clitoris, you have a lot more material to work with than you might think. In addition to the familiar tiny button (the glans), the clitoris is made up of a body, bulbs, and crura (or legs). Some people say it looks like an inverted tulip emoji; others like a high-tech boomerang or a wishbone. 

With its thousands of nerve endings, the glans is the star of the show. But the rest of the clitoris has pleasure potential, as well. Menopause might be the perfect time to explore that potential. Estrogen production falls off during menopause, causing a woman to lose up to 80 percent of her genital volume. Less circulation means less sensation. Tapping all pleasure possibilities is a smart move.

Vibrators can help, but not all vibrators are designed for the full clitoris. The Sona Cruise is. It uses sonic waves and pulses to stimulate the entire clitoris, delivering consistent intensity in use for deep-tissue massage, which can produce a prolonged climax. It’s small and quiet, so it’s discreet. With its eight patterns and varying intensities, you can find the sensation you like. Easy-to-use controls let you adjust along the way.

Explore and enjoy! When we consider that the full clitoris wasn’t mapped until 1998, we wonder what discoveries may await!

Note: The fabulous, anatomically correct pewter pendant was pointed out to me by a friend. It's made by Lennart and Josefine, of Sweden, and offered through their Etsy shop Farjil; their image used with permission. To see their full collection of nature- and anatomy-inspired jewelry, visit their online shop through this link: etsy.com/shop/Farjil

Damed If You Do

Dame products is a company that aims to design and sell “well-engineered sex toys, to heighten intimacy, and to openly empower the sexual experiences of womankind.” We carry a few of them in our online store, and we’re fans of co-founders, Alexandra Fine and Janet Lieberman, who are trying to uncouple sex toys from the provocative and erotic—the “male gaze”—and toward an everyday tool that actually works for women. 

This summer, they encountered a roadblock that’s pretty telling about where we are at as a society on sexual pleasure for women. When the New York Metropolitan Transportation Authority refused to allow ads for Dame products in subway stations, Dame filed a lawsuit against it for sexism and violation of “free speech, due process, and equal protection under the First and Fourteenth Amendments.” 

Dame had done multiple rounds of revisions on their ads, working in good faith that, if they integrated feedback from the NY MTA, their ads would be acceptable. But the MTA ultimately rejected them, calling Dame a “sexually orientated business, which has long been prohibited by the MTA’s advertising standards.”

But the MTA has allowed ads from other companies that could also be considered “sexually oriented,” including some that sell condoms and erectile dysfunction medication. Alexandra Fine, Dame’s CEO, told BuzzFeed, “I do think that there’s a really implicit and subtle bias to feeling like men need erections. It’s a health concern if men can’t get an erection, but it’s not a health concern if women aren’t having pleasure.”

While this was making headlines over the summer, it came to mind again for us in recent weeks, as we’ve attempted to navigate online advertising and to be accepted at exhibitions. We need recognition that women are not the same as men, and are equally deserving, whether in medical research or of sexual health and fulfillment. We applaud Dame’s efforts to fight gender bias.

Global Guidance for Testosterone for HSDD

Many clinicians have used testosterone to treat hypoactive sexual desire disorder/dysfunction (HSDD) in women, but it has been “off-label,” without formal guidance or FDA approval. Now a new global position statement on testosterone has been endorsed by multiple organizations worldwide, including the International Menopause Society, The International Society for the Study of Women's Sexual Health, and the North American Menopause Society. The position is the result of “an expansive review” of available evidence and is intended to help clinicians and women determine when testosterone therapy is appropriate. 

The panel that wrote the statement concluded that there is evidence-based indication for the use of testosterone for the treatment of HSDD, with the guidance that the resulting level of testosterone in the blood is in the normal range for premenopausal women. The panel concluded that there isn’t currently sufficient data to support its use to treat any other symptom or condition, including hot flashes, anxiety, interrupted sleep, depression, or breast cancer prevention.

We often rely on the FDA, and we should. But occasionally, FDA approval lags behind the data that supports the use of a treatment for a specific condition. This is one of those instances, and I hope this leads to more clinicians suggesting testosterone therapy to women with HSDD, and, as the panel suggests, to the formulation of some testosterone treatments specifically for women.

It’s Never Too Late to Begin Again

Among the joys of my medical practice are the relationships I’ve formed with women with all kinds of backgrounds, living all kinds of lives. It’s an honor to be able to provide information, problem-solving, companionship, or just a sounding board for women navigating the many kinds of change that midlife can bring. One patient was willing to share her story, in hopes of inspiring others to believe that it is possible to take hold of your life and shape it in a way that is fulfilling and joyful. 

Sometimes life brings major changes that challenge every coping skill you have ever used and known. Major changes in my immediate and extended families nearly upended my life. I was in my mid 60s and anticipating retirement in a couple years. My life had not been perfect, but I was comfortable with my identity and focus. Or so I thought. When these life-altering events breached my life’s boat, I either had to lean in and learn to steer a new direction or be capsized in the roiling seas. I chose to lean in.

Leaning in remade my life. I learned that the identity I had chosen or been taught, or perhaps both of those, was not going to carry me into this last quarter of my life. I needed to own all the aspects of myself that I had either suppressed or intentionally denied. This required many hours of therapy as I sorted out and processed with new eyes the values I had owned and the person I was. I questioned every aspect of my identity and stripped away old patterns of thinking and living. None of this was easy. In fact, it was often difficult and exhausting and probably wouldn’t have been accomplished without the guidance of a wise therapist and other supportive people in my life. 

Probably for the first time in my life, I took a long honest look at my sexuality. I was a married woman living with a man who might be considered by most people a desirable mate. He was hard-working, kind, supportive, and faithful. Our sexual life was somewhat sporadic and bland. We communicated fairly well on many things but not often on a deep level of understanding each others’ sexual needs and wants. After more than 45 years of a shared sexual life that was less than fulfilling for either of us, this was a challenging learning road. It required trust and a willingness to explore new sexual territory. All of this was vulnerable and sometimes intimidating. However, we persisted and learned to express our fears and desires. Physical expressions of love grew into emotional and spiritual intimacy not experienced before. Especially in the early months of this learning curve there were sometimes struggles with orgasm because of the aging process. We tried not to view this as failure but verbalized the joy we experienced from sharing our bodies in new, intimate ways. We experimented with massage and different kinds of lubricants and found good advice on the MiddlesexMD website. All of this was a growing and learning process of ups and downs. At times it would have been easier to give up and return to the previous patterns of our sexual life, but each new level of learning gave us encouragement to continue on this journey.  

I have often said that I am a late bloomer in life. I am. Arriving to this new place of understanding and owning myself has come later in life. Sometimes I wish I had learned these things sooner. However, at this stage in my life I have a keen awareness that there are no second chances with the life I am given. I can either choose to grow or wither away. I have chosen the road of growth and change with all the possibilities it offers. 

I believe I could not have made some of these monumental shifts had I not been blessed with a spouse who gave me space to discover myself in ways I had never explored. He truly had no idea where this process might go and who his wife might be at the end of it. However, he trusted the process and let me struggle and thrive. A wise therapist and skilled doctors have guided my thinking and encouraged me to persevere. I have been blessed with a dear female friend who encourages me, holds my trusts in confidence, and debunks my sometimes faulted thinking. God has befriended and followed and guided me on this journey in ways I have not anticipated or believed possible. I continue to appreciate every day how intricately our spiritual, physical, emotional and mental lives are woven together and how health or illness in one area affects all the others. It is never too late or too hopeless to begin again. And again.

New Study: Many Reasons Sex Declines after Menopause

Conventional wisdom is that sexual activity drops off for women after menopause because of things like lack of desire and vaginal dryness. But a new qualitative study affirms my perspective that it’s not that simple (even taking into account the way that women’s sexuality really works). 

For the study, researchers analyzed the comments of 4,418 women (median age of 64). Reading participants’ comments about their sex lives gave researchers an up-close and personal look at all the things that go into the decline of sexual intimacy. 

Lack of a partner, either through death or divorce, was the biggest reason. Sixty-five percent, however, did have an intimate partner; and 22 percent were sexually active. In their comments, they talked about the things affecting their sex lives (or lack thereof). They talked about their partner's medical condition (27 percent) or sexual dysfunction (13.5 percent) and their own physical health (18 percent) or prescribed medication (7 percent). The mentioned relationship problems (10.5 percent) or logistics (6 percent), and perceptions of aging (9 percent).

Among usual menopause-related factors, they cited low sex drive in themselves (16 percent; in their partners at 7 percent) and other menopause-related symptoms (12.5 percent). Respondents could cite more than one reason, which is why percentages exceed 100.

Perhaps the saddest statistic, for me, was that only six percent had sought medical help for sexual problems. I encourage you to be open with your doctor about whatever issues you’re facing. While not every issue can be resolved, as a clinician I know that most can be improved to the point where you can enjoy sexual intimacy again. 

Suicide in Midlife: Someone Cares

September was suicide awareness month, and before too much of October (or this Mental Illness Awareness Week) slips by, I wanted to address it. Did you know that the highest rate of suicide between 2000 and 2017 was not in teenagers but in adults aged 45 to 54? And when it comes to females, suicide rates were highest among those aged 45 to 64. In other words, our peers.

According to the Centers for Disease Control, suicide rates across the United States have increased 30 percent since 1999. Thirty percent! And while mental illness often plays a role, 54 percent of people who died by suicide didn’t have a known mental health condition.

Relationship problems, substance abuse, physical health problems, a recent or looming crisis of some kind, financial problems, criminal/legal problems, and loss of housing are all factors that contribute to suicide.

The National Institutes of Health lists these behaviors as some of the signs that someone is thinking about suicide.

They talk about:

• Wanting to die
• Great guilt or shame
• Being a burden to others

They feel:

• Empty, hopeless, trapped, or having no reason to live
• Extremely sad, more anxious, agitated, or full of rage
• Unbearable emotional or physical pain

They take steps like:

• Making a plan or researching ways to die
• Withdrawing from friends, saying goodbye, giving away important items, or making a will
• Taking dangerous risks such as driving extremely fast
• Displaying extreme mood swings
• Eating or sleeping more or less
• Using drugs or alcohol more often

If you are considering suicide, please get help. Call your doctor or the Suicide Prevention Hotline at 1 (800) 273-8255. 

If you believe a friend, relative, or your partner is considering suicide, be direct. Ask them if they have suicidal thoughts. Make yourself available to them. Listen without judging. If you’re shocked, don’t show it. Encourage them to seek help, and help them find the right resources. These are the ways you show you care, and knowing that someone does care might be enough to make the person seek help. 

HT May Reduce Incidence of Diabetes

At last week’s North American Menopause Society annual meeting, new study results were presented regarding hormone therapy and the incidence of diabetes. The study is based on analysis of the data from the Women’s Health Initiative (WHI). The particular combination of estrogen and progestin therapy decreases seven of the nine metabolites (substances produced during metabolism) that are “strongly associated” with Type 2 diabetes.

This is good information for women and their health care providers to have because it fleshes out another part of the balance of risks and benefits for each woman, especially, as the NAMS medical director, Dr. Stephanie Faubion says, “given the debilitating effects of diabetes and its increased incidence in the United States.” The study was led by Dr. Heather Hirsch at the Ohio State University Medical Center.

I’m grateful for this continuing research, and encourage women to investigate what’s currently known about hormone therapy. The more we know, the better decisions we can make about how hormone therapy might help us maintain our health. And it’s worth remembering, as Dr. Avrum Bluming said in our Fullness of Midlife interview, “Everything in life that we do is a balance of risk vs. benefit.”

More (but not new) food for thought on the HT/cancer debate

As you may have seen in the news, a new study was recently released, renewing the debate on the relationship between hormone therapy (HT) and breast cancer. Conducted by the Collaborative Group on Hormonal Factors in Breast Cancer, the study looked at data from 58 other studies, which, taken together, included over 108,000 cases of invasive breast cancer. 

Results showed that the relative risks were greater for women who used estrogen plus progestin than for estrogen alone; that risks were greater in current than in past users; and that the risks increased with duration of use in current and past users. 

How much might it increase the risk? Five years of HT starting at age 50 translates into about one extra case of cancer per year for every 50 women taking a combination of estrogen and progestin daily; an additional case for every 70 women taking estrogen plus intermittent progestin, and an additional case in 200 women using estrogen only. In women using the treatments for 10 years, the number would be twice that. No increased risk was found for women who used vaginal estrogen.

The internet loves an alarmist headline, but there are good reasons not to panic. First, the results show association, not causation (an important distinction). Second, as NAMS points out, the report is based on old prescribing practices for HT, including oral estrogens and regimens that are now rarely used because we know their adverse effects. So the report doesn’t tell us anything about the risks associated with current prescribing practices. Finally, the absolute risks are low and could be the result of a bias in the research. 

According to NAMS, the WHI randomized trials still provide the best estimate of absolute risk for breast cancer associated with the use of HRT—six additional cases per 10,000 women/year.

An important finding in the study was that obesity is itself a sufficient risk factor for developing breast cancer so that HT did not appear to add risk. That is, being obese raises the risk of breast cancer as much or more as HT, depending on other factors—like age and specifics of HT.  

For me, the findings of the study just confirm my belief that treatment for menopausal symptoms needs to be customized for each woman, given her risk factors, symptoms, and preferences. For example, the study talks about an “increased” risk for younger women who are on HT because they’ve gone through menopause early. But they have no more risk of developing breast cancer than their premenopausal friends, and taking HT until the natural age of menopause can offset the risk of developing other serious conditions.

I recommend being up on the latest information on health-related issues, but nothing beats talking to a well-informed doctor about what is right for you. 

The Case for Self-Care

As I’ve interviewed women across the country and many different fields for our podcast, The Fullness of Midlife, a couple of themes recur. One of them is self-care, which I’ve discussed with a yoga instructor, a health sciences researcher, and a cardiologist, among others. If you’re on social media, you likely see lots of posts with the #selfcare tag—everything from skipping work to training for a marathon seems to qualify. So what is self-care, really? It’s being intentional about doing something you know will preserve or improve your mental, emotional, and physical health. When done right, self-care reduces stress and enhances quality of life. So self-care will vary a great deal from person to person, age to age, and even day to day.

What I’ve noticed in my friends and patients is that midlife women resist self-care, often because they see it as selfish. Self-care involves checking in with yourself and asking, “What am I feeling?” and “What do I need?” when many women are more accustomed to asking “What is my child (or spouse or parent or colleague) feeling and what do they need, and how can I meet that need?”

I encourage my patients to think of self-care as the ultimate form of self-respect. And knowing what we need to do to take care of ourselves enables us to better care for others. Some experts compare it to putting your oxygen mask on first when you’re on a plane, before helping others. Or you can think of it as an investment that pays big dividends. Self-care gives us more energy not just to meet our obligations but to pursue our dreams. It enables us to live full and fulfilling lives.

Healthy food, proper rest, and regular exercise are universal, but beyond that, it’s really up to you to decide what self-care is. Everyone needs to decompress and rejuvenate, but that might be anything from binge-watching Netflix or having a cup of tea with a friend to skydiving or learning a new language. Finally, if something depletes you rather than energizes you, or you don’t enjoy it, it’s not self-care. Skip it!

You’re looking good down there!

I have a friend who recently decided to stop dying her hair. “I’m tired of trying to ‘do young.’ I just want to ‘do me.’” When it comes to the way we look, it seems like there’s a fine line between being your best self and just being yourself. 

To dye or not to dye used to be the only decision midlife women had to make, but now, if you have the interest, time, and money, you can lift and reshape any part of your body, from your derriere to your ears. That includes your lady parts.

In labiaplasty, the surgeon trims the inner lips surrounding the vagina (the labia minora) to make the entire area look smooth or removes the lips entirely (by the way, this will happen naturally with menopause, during which the labia tend to ‘melt away’). The surgeon can also tighten the vaginal opening, tweak the outer labia, reduce or remove the clitoral hood.

Since there’s no proof that these procedures enhance sensation, I assume that women do it because they think that area doesn’t look the way it should. Perhaps at some point they got the message that the way they are built is somehow inferior or not normal. As a practitioner, I have seen many, many women’s private parts and I can tell you that normal encompasses a very wide range. Furthermore, in surgery there’s always a risk of infection or nerve damage, which could reduce sensitivity.

You’re the only person who can decide what’s right for you, but I do hope you weigh the risk of actually having less sensation during sexual activity with the “benefit” of a cosmetic change. Don’t be swayed by anyone’s ideas of what’s normal or perfect when it comes to genitalia. 

If you have real concerns about how your vagina or clitoris are functioning (or not), rather than the way they look, talk to your medical professional. They can identify the problem and offer solutions.