October 01, 2018

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Early Warning Signs of a Troubled Relationship

In a recent post, I talked about relationship life rings—resources you can go to for extra help, one of which is counseling. Ann McKnight, a clinical social worker who is experienced with couples and families, told us that many marriages can recover from a tailspin, “if people start to work on the marriage before they’ve reached the point of total burnout and hopelessness.”

Which leads to another question: Are there early warning signs that can prevent you (or your spouse) getting to that point? There are, but they may not be the same for everyone.

One simple indicator is physical proximity. Do you spend time in the same room? Do you still sleep in the same bed? Are you engaging in the behaviors that support your physiological connection—not just sex, but doing activities side-by-side? If you notice that those behaviors changing, think hard about what might be the underlying reason.

couple not talkingCertain communication styles comprise another type of red flag. Research conducted by the Gottman Institute shows four communication styles that can predict the end times for a relationship: criticism, contempt, defensiveness, and stonewalling. Criticism is an attack on your partner’s character. Contempt is treating the person with disrespect and derision; it is the single greatest predictor of divorce. Defensiveness involves shifting blame in order to avoid responsibility. And stonewalling is simply shutting down and not responding.

The Institute also suggests antidotes to each. Instead of complaining, use “I” statements to express your feelings and need. Guard against contempt by building a culture of appreciation and respect, regularly noticing and commenting on what your partner does well. Acknowledge the role your actions have played instead of defaulting to defensiveness. And use self-soothing techniques (like reading or exercising) when you feel emotionally overwhelmed and tempted to stonewall.

If you’ve tried the antidotes and they aren’t working, it’s probably time to find a counselor.

Another indicator you might need to get help is untruthfulness. “Whatever it is that the person isn’t being truthful about, once it’s out, both partners are often relieved,” says Ann. “There’s a feeling that now that they know what it is, they can deal with it.”  

But the honest exchange has to happen earlier rather than later. Too often the other partner’s response is, “If only I had known this six months ago, when I still had the energy and the will to work on the relationship.” While you cannot know if your partner is holding something back, you can choose to be truthful yourself.

Feeling stuck is a third red flag. Everyone encounters difficulty in a relationship, but if one of you is despairing of ever being understood, then the relationship is stuck. if you can see repeating patterns of unconscious behavior that seem ingrained in the relationship, like a contentious topic that makes you say “just plug in the tape” (because the conversation never goes anywhere new), then start looking for a therapist. These unconscious patterns often have roots in what you learned about what love is from your parents. A good therapist can help you discover what’s going on so you can deal with it on a conscious level.

A therapist might also help identify something about a partner (such as where that person falls on the Enneagram; listen to our podcast on that topic) that might help you stop taking your spouse’s behavior personally. Again, the key is to get help early, while you still have energy for the relationship.

The empty nest is actually a great time to take a hard look at your marriage. By then, “you have the life experience and the mindshare to look at yourself and at how you’re contributing to what’s going on,” says Ann. “You can look backward and see patterns you probably couldn’t before.”

You also have an important insight that younger people don’t. By the time you reach middle age, “it’s likely you realize that, at the end of the day, you are responsible for how you are going to walk through [marital difficulty]. No one is going to rescue you,” says Ann. And, because of life experience, you also have enormous capacity to achieve the kind of relationship you want to have” if you’re both willing to do the work.

September 27, 2018

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Q: Why does the clitoris shrink and get less sensitive?

You say that the changes to your clitoris have affected your sex life and made you feel embarrassed. Let me assure you that this is not your fault. It’s a natural part of aging.

Here’s how it happens: Perimenopause and menopause cause a decrease in estrogen. The decrease in estrogen causes a decrease in the blood supply to the genitals, and this leads to a decrease in size of and loss of sensation to the clitoris and the genitals, in general.

If the cause is related to a loss of estrogen, restoring estrogen to the genitals (localized therapy) may be just the ticket!

Another factor could be the amount of intimacy you’re having. I always say “use it or lose it”and that definitely goes for the vagina and surrounding tissues. The less you use them, the more likely it is they’ll get smaller and less sensitive.

Vibrators for tissue healthFor those women who are not in a relationship, this is a great reason to use a vibrator. It keeps all those tissues healthier. Remember that this is a totally normal part of aging (but there are things you can do to make it better)!

September 24, 2018

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You’re Not Alone Facing Obstacles to Sex

I’ve said it before and I’ll say it again: Sex after menopause can be challenging. That’s behind many of the conversations I have in my medical practice, and a major motivation for the conversations on this website. You may have thought your sex life would actually improve as you aged. After all, the kids are moved out (or more independent), you’re likely in a better financial position, and no more periods means no worries about pregnancy.

And you may be encountering the reality that now you’re in the throes of perimenopause or menopause, your sex life isn’t quite what you imagined. You’re not alone.

I spend a lot of time discussing obstacles to sex during menopause faced by women like you. As you read through the list below, see if you identify with some or all of them. You may find that you have a lot of company on the road you thought you were traveling alone.

  • Loss of interest in sex. It’s important to know there’s nothing unusual if you have little (or no) interest in sex. Your body is going through significant changes during menopause, and one of those changes is a loss of estrogen. As a result, sexual function often decreases drastically, affecting libido and making arousal difficult.
  • Stress and fatigue. I lump these together because they often go hand in hand. All the physical and emotional changes of menopause can make you feel especially tired, and night sweats can make it impossible to get a good night’s sleep. What happens next? Your stress level rises because you’re tired. It’s a vicious cycle—one that can leave you less interested in sex.
  • Body image issues. Weight gain during menopause is common. If this is something you’re experiencing, you may not be feeling as sexy as you once did. Your partner may be telling you that you’re beautiful, but that’s not what you see when you look in the mirror. Feeling less sexy can also make you feel depressed or anxious and unable to enjoy sex.
  • Boredom in the bedroom. It’s hard enough to get aroused with all the menopause changes stacked against you. Throw in the same old routine in the bedroom, and your chances of having a night of passion are probably not great.

If you can relate to any or all of these, be assured there are others who have shared your experience, and have sought out ways to surmount each obstacle. Don’t be afraid to talk to your partner and be honest about how you’re feeling. Use this website or print pages from it to prompt discussion. If you feel like your symptoms are more than you can address on your own, make an appointment with your health care provider to investigate solutions.

The best time to work on the challenges of sex during menopause is now. You have years of great sex ahead of you; don’t waste time trying to figure it out alone.





September 20, 2018

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You Can Manage “The Change”

Before it became okay to call menopause by its name, women called it “the change”—with good reason. The waist thickens, the hair thins, and sleep goes haywire. You may be wondering if there is anything that doesn’t change after menopause. There might be (your favorite food?)—but add your vagina to the long list of things that do.

Declining estrogen changes the vaginal lining, making it thinner and less elastic. The official term used to be vulvovaginal atrophy (VVA), and you may see articles using that term (or hear it from your health care provider). Now, more accurately, it’s called the genitourinary syndrome of menopause (GSM). Symptoms include

  • Vaginal dryness, irritation, or burning
  • Burning and/or urgency with urination
  • Urinary tract infections
  • Urinary incontinence
  • Discomfort and/or light bleeding after intercourse

Yes You Can: Dr. Barb's Recipe for Lifelong Intimacy

A new study by European Vulvovaginal Epidemiological Survey (EVES) points to just how prevalent this condition is. In the study of over 2,000 women between the ages of 45 and 75, a gynecological exam was done on each woman who reported one or more symptoms. In 90 percent of those women, GSM was confirmed.

Women often overlook GSM, either because they aren’t aware that the condition even exists, or because they think of each of their symptoms as individual problems, rather than collective evidence of something else.

But as the EVES study also showed, women with GSM also experienced a lower quality of life than those who didn’t have GSM. That’s unfortunate, because, although GSM is chronic, it’s also treatable with, for example, localized (vaginal) estrogen or non-estrogens that restore health to genital tissues.

Your doctor can help, but only if you let your doctor know about your symptoms. So take a deep breath and explain what’s been going on. Once you begin treatment and see that there are ways you can manage the change, rather than just letting it happen to you, you’ll feel a whole lot better.

September 06, 2018

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Q: Why do I have a stinging, burning sensation when I urinate after sex?

You say that you have that sensation even though you’ve had Mona Lisa treatments [a procedure for restoring vaginal tissue] and use Uberlube, and that sensation continues for a couple of days after intercourse.

It’s possible you could have one of three conditions: atrophic vaginitis, vulvodynia, or a urinary tract infection (UTI) caused by intercourse.

The Mona Lisa Touch therapy doesn’t completely take care of atrophy for some women, and you might be one of them. If so, there are safe and effective prescription therapies available, and it may be helpful to add one of those.

Vulvodynia happens when the entrance of the vagina becomes inflamed, causing burning pain during and after intercourse.

Finally, in some women intercourse itself actually causes a UTI, a bladder infection that causes the symptoms you describe.

Those are the most likely possibilities, but please talk to your provider about what’s going on. She or he can determine the cause and recommend the best course of treatment for you--and there is treatment for each option.

September 03, 2018

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Life Rings to Reach for When Things Are Bad

We talk a lot about how to stay connected to your partner and build intimacy (and last week's post was about taking advantage of your new empty nest). But what if, in spite of your best efforts and intentions, the relationship is still unsatisfying? Here are a few places you can look for help.

Books. How do you find the good ones? Ask people you trust for recommendations. Books that my patients have found helpful include: The All or Nothing Marriage: How the Best Marriages Work (Eli Finkel), The Five Love Languages (Gary Chapman), Ten Lessons to Transform your Marriage, and The Seven Principles for Making Marriage Work (John Gottman).

Podcasts. Esther Perel has a great podcast called “Where Should we Begin.” Each episode features a couple in an actual counseling session with Perel, who helps them articulate their feelings and get to the bottom of what’s really going on.

Weiss quoteSeminars and retreats. Using Google, you can find everything from reasonably priced retreats hosted by religious organizations to pricey seminars hosted in scenic locations by marriage experts (often authors of books on marriage). Be sure to do your research and discuss what you’ve learned and what you expect with your partner before signing up. Some are classroom style with small group breakout sessions, while others may include public roleplaying, couples counseling, or game playing designed to foster connection.

Counseling. A good marriage counselor can help identify the underlying issues in your relationship and then facilitate the conversation as you work through them together. Look for counselors who specialize in marriage and family counseling and find out what kind of approach they use. Cognitive behavioral therapy, which focuses on changing negative thoughts and behaviors, is quite different from a Freudian approach, which focuses on unconscious meanings and motivations. Imago relationship therapy (IRT) is another approach; it explores how emotional wounds in childhood affect adult relationships so partners can better understand each other.

Marquez quoteHow will you know if a counselor is good? Our friend Ann McKnight, a clinical social worker who is experienced with couples and families, has some thoughts. After the first session, you’ll likely have an idea of whether or not the person understands the issues and can offer a direction that makes sense to your and your partner.  Don’t be afraid to ask about the counselor’s training and experience working with couples, as well as what kinds of outcomes they see. And, she says, “Do your own homework, as well, in considering ahead of time what outcomes you are hoping for from the process. Willingness to take ownership for your own role in the challenges of your marriage is important.”

All marriages go through rough patches. Often, they can recover with some extra help. Ann says that, of the couples she sees “an extremely high percentage of marriages can recover, particularly if people start to work on the marriage before they’ve reached the point of total burnout and hopelessness.”* It’s important to point out that she sees a self-selecting group in that they have sought out therapy—but you would fall into that category, too.

Whatever you do, don’t wait. Just like with your physical health, the sooner you address whatever the issue is, the greater the chance that it can be fixed.


*This holds true as long as there’s no domestic violence and/or untreated substance abuse.



August 30, 2018

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The Empty Nest Reset

It’s move-in weekend at the college in the town where I work, and seeing all those packed minivans crawl along the side streets, trying to find their way to the right dorm, makes me think of the parents who drove out of the driveway with their youngest child and a full vanand will return with an empty van to an empty nest.

Some will break out the champagne; others will retreat with a box of tissues. And some will do both within 20 minutes. It’s a wild time.

Emma Thompson quote

This built-in transition also happens to be the perfect time to reset your relationship with your significant other. As with so many other things we talk about, the important thing is to be intentional. As Dr. John Gottman says, couples often ignore each other’s emotional needs “out of mindlessness, not malice,” so being mindful is critical.

In the first few days, give each other some space. Everyone has their own way of processing this major milestone, and you may find that your partner’s way is a lot different than yours. It’s okay. As long as the behavior isn’t harmful, live and let live. If your partner goes silent in those first few days, check in occasionally, but don’t hover.

If you suddenly realize you’ve drifted apart over the last few years (or decades), row back together. Raising children is a demanding job, and many couples are surprised to find that while they were busy tending to their children’s needs over the years, they lost track of each other. It’s not too late to find your way back to each other. There are many ways you can do it—all of them start with acknowledging that you’ve drifted and desiring to come back together.

Without children to monitor and guide, it can be tempting for partners to monitor and guide each other. Resist the temptation. Instead, look for the good in your partner, including the things that you might be taking for granted, and express appreciation. Every time you do, you are making a deposit in what Gottman calls “the emotional bank account,” and you can draw on that bank account during hard times. Ideally, that account is healthy before you get to the empty nest, but it’s never too late to start.

Rediscover the things you used to enjoy doing together before the kids’ needs and activities commandeered your time. You could start by having a dinner conversation reminiscing about your dating days. How did you like to spend time together then? Then try to remember what, over the years, you said no to because there wasn’t time. Going on a mission trip? Hosting a salon to discuss literature or art? Which of those things are you still interested in? Then make a plan together for doing them.

Emma Thompson quoteFind a new interest that’s yours and yours alone. I know. I just said to find things to do together. But the truth is that you need both. Pursing your own passion is not just rewarding for you—it can also be intoxicating to your partner, who will see you with fresh eyes. In her research, Esther Perel found that one of the times a person is most attracted to their partner is when watching the other do their thing from a distance. “When I look at my partner, radiant and confident, [is] probably the biggest turn-on across the board,” says Perel. She’s a big advocate for nurturing both intimacy and mystery (AKA security and passion) in relationships, and doing something new is a way to amp up the mystery.

With time and effort, your relationship can be more satisfying and simply more fun than ever. Enjoy it! And appreciate it while it lasts, because those children might come home again. Thirty-two percent of children 18 – 34 live with their parents, according to Pew Research Center. But that is a topic for another time.

To raise the topic of renewed intimacy with your partner, or to support mindfulness for yourself, check out our Empty Nest Kit

August 27, 2018

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The Benefits of High Intensity Workouts

Yoga, stretching, weight lifting, aerobics—they’re all forms of exercise, and they’re all good for you. But, do they all give you the same boost in the bedroom?

It’s true that any form of exercise is good for you and may help you lose weight, build muscle, and improve body image, among other benefits. These are all compelling reasons to get moving or keep moving if you already have an established exercise routine. But, there is one form of exercise—strength and high intensity workouts—that may help spice things up in the bedroom.

Research (from health.com) shows that physically active women have a greater sexual desire, increased arousal and higher satisfaction than women who do not exercise. In addition, another study (also from health.com) among physically inactive men who began a strenuous workout routine reported “more frequent sexual activity, improved sexual function, and greater satisfaction. Those whose fitness levels increased most saw the biggest improvements in their sex lives.”

In addition, any exercise, especially strength training, can increase testosterone levels in both men and women. You may already know that, but did you know higher testosterone levels may increase your sex drive—and your partner’s as well?

That could be a good reason to start doing some high intensity workouts with your partner. A win-win for both of you between the sheets!

High intensity and strength training workouts can also have other benefits that many women don’t think about: improved stamina and durability, and stronger orgasms. You and your partner will likely enjoy your sexual encounters more if you’re not gasping for breath or sweating profusely part-way through your sex date.

More research has shown that strength training had “the strongest relationship to overall satisfaction with quality of orgasm.” And many studies show a correlation between aerobic exercise and quality of orgasm.

If you’ve been thinking about increasing your activity level or looking for ways to heat things up with your partner, consider adding strength training and/or high intensity workouts to your routine. I think you will be pleased with the results—in more ways than one!

August 23, 2018

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Thank You, Aretha: Queen of Soul

When Aretha Franklin sang “Respect,” “It was a demand for equality and freedom and a harbinger of feminism, carried by a voice that would accept nothing less,” writes the New York Times. We agree.

Born in Memphis to a preacher and raised singing gospel in New Bethel Baptist Church in Detroit, Franklin had a “both/and” life, experiencing hardship alongside success. Her parents separated when she was six, and her mother died just a few years later.

Things didn’t get any easier. Franklin had two children by the age of 15, married at 19 a man who managed and physically abused her, and struggled with alcohol and marijuana for a time as an adult. In the 1980s, she lost her father, her brother, and a sister.

Sometimes, what you're looking for is already there. Aretha Franklin

But alongside the pain (some say as a result of it), she experienced lasting success and fame. Songs like “Respect,” “Think,” “Chain of Fools,” “Ain’t Nothing Like the Real Thing,” and “Freeway of Love” are included in many of our personal soundtracks of life.

She received far too many awards to list, but they include induction into the Rock and Roll Hall of Fame (1987), a Grammy Lifetime Achievement Award (1994) and the Presidential Medal of Freedom (2005). Beyond her professional achievement, she was deeply committed to and engaged with her community. And Aretha set an example in owning her own body and appearance, embodying self-worth and self-love.   

Like the rest of us, Franklin was human—not perfect. She jealously guarded her “queen of soul” title and could be difficult to deal with. And she was a strong women who sang powerfully and, in so doing, inspired others to respect themselves and demand that others do the same.

August 21, 2018

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Time to Find a New Doctor?

This is your life—you deserve to get what you need from your doctor. If you aren’t getting your questions answered when you go for an appointment, what’s the point of being there? Right? Your physical and emotional well-being are important, and if both of those needs are not being met at your doctor’s office, you may need to speak up or make some drastic changes—maybe even both.

Women need to feel entitled to care for themselves.

Think of it this way: If your car needed repair, you wouldn’t take it to just any random mechanic to be fixed: You’d ask your friends for referrals, you’d check online reviews, and you’d have a conversation with the mechanic to be sure he or she can communicate with you about what repairs are required and why.

You should expect at least as much from your health care provider as you do your mechanic. When you leave your appointment, you should honestly feel that you were able to discuss your concerns openly and get your questions answered. If not,  you can empower yourself to get what you need from your current provider or find a new one.

So, here are eight signs that you may not be getting what you need from your current health care provider and might need to start shopping around:

  1. You are being treated like a man. It’s no secret that, in the past, medicine has been dominated by men. Drug trials using animals were typically done with all-male specimens, and clinical trials were done using—you guessed it—all male candidates. So it’s no surprise that dosage amounts for drugs have been based on the “average male.” The good news is that researchers are now changing gears and looking at how both men and women react to various drugs, treatments, diseases, and side effects. The bad news is that the gender divide lingers. If you don’t feel like you are being heard, and your doctor is talking to you like a bowling buddy or a fragile flower, he or she is probably not sensitive to your needs as a woman.
  2. You wait weeks (maybe even months) to get an appointment. While this may mean that he or she is an excellent physician, it really doesn’t do you any good if you can’t get in the door. If she or he has such an extensive patient list and you aren’t a priority, it will be in your best interest to look for someone else. The same is true if you have to wait an hour (or two) every time you see the doctor or you have to call five times to get your test results.
  3. Your doctor is uncomfortable talking about certain topics. If you have questions about topics like sexual intimacy, bowel movements, or sex toys, and your doctor is reluctant to discuss any of them, your appointment may be a waste of your time. If you can’t be honest with your physician, your level of care may be compromised. You may be reluctant to name over-the-counter supplements your doctor’s implied are foolish, which could mean your doctor can’t fully assess interactions with your prescribed meds. If you find yourself leaving your appointments with too many unanswered questions, it might be time to make a change.
  4. Your doctor writes you a prescription before you finish your first sentence. If you are in the examining room for only two minutes and the doctor already has paper and pen in hand, beware! Sometimes, in the press of time and the desire to provide a solution, a doctor will short-change the conversation that leads to a confident diagnosis.
  5. Something just doesn’t feel right. It can be something as simple as a personality conflict or a communication style. It’s okay to trust a feeling of discomfort you have. If you’re not comfortable in the relationship, you’re less likely to be as open and honest as you need to be to forge a strong patient-physician partnership for managing your health.
  6. The office staff makes your life difficult. Are you on hold for 20 minutes (or more) when you call the office? Is the office staff rude when you finally get through? You deserve to be treated better than that! First, describe your experience to your provider; he or she can’t solve the problem if it’s invisible to them. If things don’t improve, decide whether dealing with the office is making you avoid addressing health issues—and if it is, consider alternatives.
  7. Your doctor talks down to you. Your questions are valid and important. The last thing you need when seeking care for a problem is condescension. If it’s implied that you’re not likely to understand your own issues and treatment, assert yourself and remind your doctor that you are ultimately your own health manager.
  8. Your doctor likes to work alone. Especially if you are a complicated case, your doctor may need to coordinate with your other health care providers. If he or she is reluctant or won’t communicate with others involved with your care, it may be time to make a switch.

Going to your doctor may never be “fun,” but it doesn’t need to cause you added stress and anxiety. If you don’t feel like you’re getting the care you need—including for symptoms of menopause— from your health care provider, ask yourself if you need to make a change. It may be the best thing you could do for yourself—and you do deserve care!