November 10, 2010


arousal ›   intimacy ›  

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.

November 08, 2010

1 comment

comfort ›  

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.

November 05, 2010


arousal ›   intimacy ›   women's sexual health ›  

Sexual Variety in America: Forty-One Ways to Love Your Lover

We're learning. I was happy to see that confirmed by Indiana University’s Center for Sexual Health Promotion's findings in the latest National Survey of Sexual Health and Behavior.

I was glad to see that more Americans of all ages report they are engaging in a variety of sexual acts in addition to -- or instead of -- vaginal intercourse. Compared to the last survey, in 1994, more people are masturbating (alone or with a partner), giving or receiving oral sex, and generally experimenting with a medley of different sex acts: 41, to be exact.

And that doesn’t even include the use of sexual aids like vibrators.

This is good news for everyone, but especially for women -- and especially for women of a certain age. As this latest study confirms, women are less likely then men to experience orgasm during vaginal intercourse without additional stimulation. And as we get older it takes often takes additional additional stimulation to get the kind of sexual release we got used to enjoying in our 20s and 30s.

Feeling free -- and knowing how -- to mix it up, to combine several ways of making love in a single sexual encounter, makes it easier for women and the partners who love them to experience the full range of intimate pleasure.

The National Survey of Sexual Health and Behavior found that women were more likely have an orgasm if their partners used more than one technique in bed. Fifty-four percent of women who had “one-act” sex during their last encounter reported having an orgasm, while 89 percent of women who included five sex acts in their most recent assignation enjoyed orgasm.

Another piece of good news from the study: among women 50 and older, solo masturbation was more commonly reported than most other sexual behaviors. To me, this suggests that masturbation is not only less taboo among older women that it once was, it also indicates that more women are actively maintaining their bodies for sexual enjoyment. As a doctor who specializes in the health of women over 40, I’m a strong advocate of self-stimulation. It helps us remain sexually healthy and responsive (not to mention in a good mood) during times when we are without partners. When we have partners, it can help prepare genital tissues for comfortable intercourse and/or orgasm.

You may not aspire to all 41 acts. But if you’d like to expand your sexual repertoire, our website offers information and products that can help you expand your knowledge and pleasure. Branch out!

November 03, 2010


intimacy ›   women's sexual health ›  

Connection: The Second Component of Great Sex

We’ve talked about how crucial mindfulness--being mentally and emotionally present in the moment--is to enjoying great sex, sex that is “better than good,” as reported in a study recently published in The Canadian Journal of Human Sexuality.

I like to think of “connection,“ the study’s second ingredient of optimal sex, as “mindfulness times two.” Connection is what happens when both partners are present together: in bed, in the moment, in each other. As one study participant describes it: “Inside my body I’m the other person’s body and we’re just all one together at that moment.”

This sense of merging, of “two becoming one,” was regularly cited as part of the experience of great sex, which has to involve “at least one moment,” as one woman said, “where I can’t tell where I stop and they start.”

I believe that this kind of intense sexual alignment is something that becomes more accessible to us as we get older. Part of our maturity is greater acceptance of self and others, which leaves us more open to making a deep physical and spiritual connection with another person. To experience the joy of merging, of temporarily letting go of the sense of any boundary between the self and the other, a person has to know herself well--and feel safe and respected by her partner.

Which brings me to two great impediments to sexual connection: unsafe relationships and sexual trauma. If you have reasons for not feeling completely safe with a particular partner, or if you have a history that leads you to feel unsafe whenever you are in a sexual situation, you’ll need to address these issues before you can experience intense connections in intimate relationships. There are resources that can help.

But for two self-aware people who respect and desire each other and who are capable of being completely present with each other in the moment, a deeply satisfying sexual connection can happen even without penetration or orgasm. The study’s authors report that great sex is often more about the level of energy between partners than about the actual physical act itself. (Check out our website’s alternatives to intercourse for imaginative techniques for increasing sexual energy and connection.)

Have you experienced these moments of sexual oneness? What were the circumstances? We’d love to hear your stories!

November 01, 2010


comfort ›   hormones ›  

Q: What can make penetration less painful?

Oooh! "Less painful" is a difficult goal; I'd like penetration to be pleasurable for you!

I'd like you to start with a thorough exam by a gynecologist or someone who specializes in women's health. If the problem is vaginal/vulvar atrophy, then localized estrogen may help to restore some moisture and elasticity. What you describe could also be caused by vulvodynia, which can cause burning sensations and pain with penetration. Again, a healthcare provider experienced in treating mid-life women can help you evaluate options.

If atrophy is profound and longstanding, you may find vaginal dilators helpful, too, in regaining caliber--the size of the vaginal opening.

I do hope you'll investigate--and raise your expectations. The minimum you deserve is no pain; I know you can have enjoyable sex again!

Sexual Satisfaction: All in Our Heads?

I saw a headline that irked me in’s Broadsheet a week or two ago. I couldn’t quite put my finger on why it bothered me until I wrote a post about the cancelation of the flibanserin project last week.

The headline was “Forget the pink pill, try a placebo.” The article opened by saying that “Researchers are desperate to discover ‘female Viagra,’ but Cindy Meston says sugar pills might hold the key.”

Meston, a clinical psychology professor at the University of Texas at Austin, co-authored a study, published in the Journal of Sexual Medicine. Reviewing data from an earlier clinical trial of a drug treatment for low sexual arousal, she noted that about one-third of the test subjects who were given a placebo instead of the actual drug reported they had more “satisfying sexual encounters” during their “treatment.”

The Broadsheet reporter takes these findings as “a reminder that in the rush to ‘treat’ female desire, there is one organ researchers can’t forget: the brain.”

That’s a conclusion I certainly agree with: Mindfulness influences our sexual behavior. More simply, when we think about sex, we have more sex.

So let me get back to what bothered me about that headline: Yes, the brain is a critical and often under-estimated part of women’s sexual response. But it doesn’t function alone. It requires and interacts with hormones, which trigger physical responses that depend on our circulatory systems and tissue health. And the brain functions within the context of our histories and cultures and relationships.

Suggesting that a placebo is the answer for every woman’s sexuality oversimplifies and trivializes the issue. (In most clinical studies, by the way, placebos get about the same 30-percent response rate, so this study isn’t remarkable by that measure.)

Meston herself isn’t proposing that placebos are the answer: “Expecting to get better and trying to find a solution to a sexual problem by participating in a study seems to make couples feel closer, communicate more, and even act differently towards each other during sexual encounters.”

That’s definitely the first step—to be intentional about taking control of and improving our own sexual experience, involving our partners when we can. Any pattern at all that helps to focus our attention will help—whether it’s a before-bed routine with a partner, a sensual lotion that’s part of our self-care, or even taking a sugar pill.

But if that’s not enough, it’s because while it’s in our heads, it’s also not in our heads.

October 25, 2010


intimacy ›   women's sexual health ›  

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 22, 2010


women's sexual health ›  

Another Dead End for “Pink Viagra”

It’s official. Boehringer Engelheim, the German pharmaceutical company, has shelved its plans to develop flibanserin. They’ve decided to focus on other drugs that “have better potential to make it to market.”

The pill’s been called “pink Viagra” because it was hoped it would do for women what other drugs have done for men with erectile dysfunction. I know flibanserin has been controversial. The drug was rejected by both an advisory panel and FDA staff, and much of the discussion about the project cancellation has focused on the negatives.

I don’t argue with concerns about Boehringer Ingelheim’s research or focus on marketing instead of fact-finding. But I do know that some of my patients who struggle with a loss of desire are desperate for more options that offer hope. They’re well-informed about their condition and their choices, and they’re fully capable of making decisions about the trade-offs between side effects and a return to a more complete sexuality.

The broader issue for me is the lack of focus on pharmaceutical options for women. Pfizer, makers of Viagra, canceled research into a female counterpart in 2004. Boehringer Ingelheim appears to be saying that it’s just too hard to follow through on a drug for women. What are the barriers? Are they cultural? Is male sexual satisfaction easier to talk about? To measure? To “monetize”?

As a physician, I want the most possible options to explore with my patients. Sometimes mindfulness, information, localized hormones, and tools like vaginal dilators are enough to change a woman’s life. Sometimes they’re not. I’m optimistic about ongoing research about testosterone for women’s sexual health, but I’d like to know that pharmaceutical companies see the issues we face as clearly and as important as I do.

Have you found a drug treatment that’s helped? Are you with me in thinking more options to consider is a good thing? Or would you rather pharmaceutical companies keep their focus elsewhere? Lots of voices will help them set their agendas.

October 20, 2010


intimacy ›  

Being There: The Number One Component of Great Sex

In an earlier blog post we reported on a study published last year in The Canadian Journal of Human Sexuality called “The Components of Optimal Sexuality: A Portrait of ‘Great Sex.’” Analyzing interviews with 20 sex therapists and 44 people who reported having experienced “great sex,” the researchers identified eight major components of “optimal sexuality”sex that is “beyond functional, beyond positive and satisfactory, beyond good.”

It didn’t surprise me at all to read that the number-one component, the one that was brought up most frequently by both experts and “practitioners,” was “being present.”

We’re not talking, of course, about being literally, physically present (although that’s fairly essential), but about being mentally and emotionally there in your body, in the moment. Here’s how one woman who was interviewed for the study put it:

“The difference is when I can really just let go and completely focus and be in the moment and not have that, you know, running commentary going through my head about anything else.”

For women our age, that running commentary is likely to include not only the long to-do lists of our everyday lives (what am I going to fix for dinner? how can I convince Mom that she really does need that hearing aid? I hope Sally’s midterms aren’t stressing her out too much), but the new and nagging concerns that come with middle-age sex (does my face look more wrinkly when I’m on top? is he going to be able to keep his erection this time? I’ve really got to get back into a regular routine at the gym).

There’s plenty of evidence that the practice of mindfulnessnon-judgmental, present-moment awarenesshelps people manage things like stress and depression. It only makes sense that intensely focused attention, the ability to be fully aware of sensations experienced moment by moment, would be a central feature of sex at its best.

If you feel sometimes that you are not totally “there” during sex, that you’re distracted or just going through the motions, consider learning more about meditation and mindfulness. Being more present in all aspects of your life will help you more fully experience the pleasures and sensations your body is designed to feel.

Watch for more “components of great sex” in future posts, and let us know what you think. We’d love to hear what makes it “better than good” for you!

October 18, 2010

1 comment

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...

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