October 13, 2010

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arousal ›   exercise ›   intimacy ›  


Sagging Libido? Tone It Up with Yoga

There are many “natural” reasons women our age begin to lose interest in sex. Hormonal changes, diminished energy, lowered self-esteem as we mourn the loss of our youthful bodies -- a complicated mix of physical, psychological, and social influences conspire to make us feel less sexy and less sexual.

When patients ask me about “natural” ways to increase levels of arousal and desire, my prescription almost always includes a combination of mindfulness and exercise. Awareness techniques like meditation help us focus on the moment and block out the stress and distractions of our everyday lives. Exercise increases blood flow, releases endorphins, tones our muscles and our perceptions of ourselves as strong and attractive.

I wasn’t surprised then, to read in a recent issue of the Journal of Sexual Medicine that yoga, a practice that combines both of these libido-enhancing elements, “improves several aspects of sexual functioning, including desire, arousal, orgasm, and overall satisfaction” -- particularly among women over age 45.

This study, which surveyed healthy, sexually active women before and after a 12-week program of daily yoga practice, found significant improvements in all of the areas measured: desire, arousal, lubrication, orgasm, pain, and overall satisfaction. Nearly 75 percent of the women who participated in the study “said that they were more satisfied with their sexual life following the yoga training.”

Other research has found that yoga increases body awareness and can be used to direct blood flow to the pelvis to enhance arousal and lubrication. The mindfulness that yoga teaches and requires helps a woman be more aware of her body and its needs. “When you’re present, you know what you need to feel fulfilled by your partner,” explains one expert. “You can then translate and communicate this deeper understanding to your partner during sex.“

And of course the increased flexibility and improved muscle tone that come with regular yoga practice help a woman feel more confident and attractive -- in bed and out.

If you’re looking for a natural way to tone up your libido, find a yoga class. And let us know how it works for you!

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

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

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

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

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

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

October 06, 2010

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conditions ›   hormones ›  


Q: Would a vaginal moisturizer help with bladder function?

No, I'm afraid a moisturizer won't help with bladder function. Moisturizers really only improve the tissue condition in the vagina where they're applied.

The vagina and the base of the bladder and urethra do have some tissue characteristics in common--they have the same embryonic origin. They both, for example, have estrogen receptors. That means that localized estrogen in the vagina can influence bladder function like frequency and urgency. Estrogen for localized application comes in several forms, but moisturizers don't contain estrogen.

If you are bothered by urinary urgency or frequency, I'd encourage you to see your medical practitioner; there can be multiple causes and there are solutions for each!

October 04, 2010

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anatomy ›   hormones ›  


What Do Breasts Do for Us?

Recently I treated a patient who’d had elective breast reduction surgery. Nerve damage during the procedure had caused her to lose all sensation in her nipples. She found herself unable to have an orgasm without the extra stimulation those nerves had provided. That was a consequence she hadn't thought to ask about!

Changes in nipple sensation are possible side effects of any type of breast surgery, including elective surgery to increase or reduce breast size. Sometimes the effects are temporary, but they can be permanent. It’s important to understand these risks -- and the role your breasts play in sexual arousal and satisfaction -- when choosing breast surgery for cosmetic reasons. I don't know if my patient would have made a different choice, but she may have.

How do breasts contribute to orgasm? Some women (not most) can reach orgasm through nipple stimulation alone. Others rely on intense breast and nipple fondling to “put them over the top” during oral sex or vaginal penetration.

Like the clitoris, nipples are bundles of nerve endings that respond to touch by releasing certain hormones in the brain. One of these hormones, oxytocin, is sometimes referred to as the “cuddle hormone”: It makes us feel warm and open toward the person whose touch initiated its release in our bodies. Other hormones, including testosterone and endorphins, combine to create a surge of sexual arousal that increases blood flow to the clitoris and stimulates vaginal lubrication.

For most women, sexual foreplay is essential to getting us interested in and ready for intercourse or penetration. And for most women (82 percent in one study) breast and nipple stimulation are an essential ingredient of foreplay.  We talk a lot about clitoral stimulation and vaginal maintenance for maintaining our sexual satisfaction, but other parts of our bodies also play a part in arousal and orgasm, though.

For those of us fortunate enough to retain the pleasant sensations our breasts can provide, remembering these important sites of arousal during foreplay and intercourse (warming and massage oils can work wonders here) will enhance our readiness for and enjoyment of sex -- at any age. Let's not forget to raise our focus -- to our breasts.

September 29, 2010

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intimacy ›  


Q: I'm not interested in sex at all. Is it all in my head, as my husband says?

A declining interest in sex as we age is typical for women, but many face a couple of additional factors that are really big: 1) It is painful; and 2) the event itself may not be particularly engaging. Is it any wonder that there isn’t much motivation to participate?

If you have pain, you need to find a practitioner who can help solve that issue. There is almost always a solution for pain with intercourse. NAMS (The North American Menopause Society) is a good resource for finding a certified menopause practitioner if you feel your provider isn’t able to find a solution--or you're not comfortable discussing the issue with him or her.

The other issue is more difficult to address. After years, maybe decades, of a less-than-fulfilling sexual relationship, it is hard to reinvent, but most women would agree it is worth trying. For some menopausal women a great sexual relationship doesn’t even need to include vaginal penetration, but that takes a caring, nurturing partner.

Your partner needs to understand that romance and emotion are key to improving your libido--and you need to feel confident that you deserve that... because you do. For some women testosterone, in addition to that intimacy and foreplay, can make a remarkable difference in libido. Again, finding the right provider to investigate that option would be beneficial for you.

Some women have told me that visiting our site with their partners has been helpful. You might review the bonding behaviors together to start a conversation about what kind of foreplay and attention you need for a better opportunity for comfortable--even satisfying!--sex.

Your lack of interest is not in your head! I have yet to see a woman with pain with intercourse for which I couldn't find some cause and some solution options. Things to explore with a menopause care provider are atrophic vaginitis, vulvodynia, or vaginismus. Sometimes localized estrogen is required in addition to HRT to fully estrogenize the vagina.

There are solutions out there! Please explore them fully. Good luck, and don’t give up!

You Never Know: Staying Ready for Sex

I had a call the other day from a friend who’s been a widow for several years. “I’ve found someone!” she told me, with just the slightest quiver in her voice. “I’m so excited I can hardly concentrate at work.”

Of course I was happy for her -- and happy that she called to set up an appointment with me for an exam in anticipation of resuming her sexual life. “I think everything’s going to be okay,” she said, “but I think I might want to come in and see you first so you can tell me for sure.”

She did come in to see me and I was glad to be able to reassure her that, from a physical perspective, she was good to go. If I am able to place two fingertips in a patient’s vagina without causing pain or discomfort, it’s a good bet that she’s going to be able to have intercourse comfortably.

But more than a few post-menopausal patients who come to my office have been astonished to discover that they can’t pass the two-finger test. Their vaginal walls have narrowed and thinned over a period of time without regular intercourse, and I have to tell them it’s going to take some work to get back into a condition where penetration will even be possible, let alone comfortable.

I run into this fairly frequently with women who are widowed and divorced at our stage of life. They are grieving or angry -- or both -- and, without thinking too much about it, decide that their sexual days are behind them. Don’t need to worry about that anymore! But, as my ecstatic friend can attest: You never know. Surprises happen, and when they do, it sure would nice to know that your body’s ready and able to experience the pleasures of intercourse.

It’s one of my biggest concerns for single women our age. If you’re 30 when you divorce and 40 when you want to take it up again, there’s been no lost ground. But if you’re 50 and decide to resume sex at 60, it’s a very different story. You find yourself in a new relationship, you’re ready to be intimate, but your vaginal “architecture” has changed. It can be a very unhappy surprise.

Physical therapy with vaginal dilators can help to restore capacity for intercourse, but it’s much simpler -- and more pleasant! -- if you don’t lose that capacity in the first place. For all my patients and friends who are currently without partners, I recommend a “vaginal maintenance plan” that will help them keep their genitals healthy and ready for love: moisturize regularly; use a good lubricant; and experiment with a personal vibrator or dilator to preserve your capacity for penetration.

Because you never know.

September 24, 2010

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comfort ›   hormones ›  


Q: Can I get an over-the-counter estrogen cream for vaginal dryness?

Estrogen-containing vaginal preparations are prescription only. If you haven't tried lubricants and moisturizers, which are available over the counter, you might try those first.

Lubricants are designed for short-term effect, to make intercourse immediately more comfortable. They can be water-based, silicon-based, or a hybrid of the two.

Vaginal moisturizers are designed for longer-term maintenance of your vaginal tissues. They don't contain hormones, so don't require a prescription. They're typically used every several days.

Localized estrogen, which is available as a ring or vaginal tablet in addition to cream, helps to increase blood flow and elasticity in genital tissues. If you've tried lubricants and moisturizers and haven't yet been comfortable during sex, consider talking to your health care provider to see if localized estrogen or another hormone therapy might be right for you.

Can We Talk? I’m Not Sure.

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

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

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

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

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

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

September 20, 2010

1 comment

intimacy ›   men's sexual health ›  


Satisfaction: It Works Both Ways

I saw a patient this week who is in her early 60s, in great shape, and happily married to an attractive and generally healthy man also in his 60s. Recently retired from executive positions, they have been traveling to exotic -- and romantic! -- locales, enjoying fine cuisine and luxury accommodations.

They haven’t had sex in two years.

My patient told me that her husband had started having problems maintaining an erection since beginning medication for hypertension. After a series of failed attempts at their usual way of making love, they had given up trying to have intercourse. When I asked her if they pleasured each other sexually in other ways, using oral or manual stimulation for example, she simply shook her head.

This female response to male erectile dysfunction -- not an unusual one by any means -- intrigues me.

When the female half of an otherwise healthy, happy, heterosexual couple experiences a condition that prohibits penetration, she is typically eager to explore other options for sexual intimacy. But it doesn’t seem to work the other way. It’s like if he’s not going to get the ultimate end result -- orgasm -- then neither of them are.

I suspect what happens is that when men have difficulty performing, they start initiating sex less often. So once a week becomes once a month, and then there’s a problem and three months go by and it doesn’t work that time either, and -- then it’s done!

What’s up with that, girls? Do partners with erectile dysfunction really lose all interest in any type of sexual intimacy? Or is it just hard  -- for both of you -- to change the game plan, the way sex happens, the way it starts, the way the “end result” is achieved or defined?

My guess is that many of these men would welcome their partners’ attempts to change things up, to experiment with new techniques and sensual aids that can enhance pleasure on both sides.

What’s your experience? What have you tried? What has worked -- or not? Other women would love to learn from you!

September 15, 2010

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arousal ›   intimacy ›   women's sexual health ›  


Missing Orgasm: Is It Me or My SSRI?

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

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

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

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

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

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

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

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

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

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