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.

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!

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.

Q: I quit the pill and tested mid-menopause in one month; now sex hurts. Suggestions?

Isn’t it amazing how quickly things can change? You say you were tested as being mid-menopause. Blood work is accurate at assessing ovarian function on the day you're tested, but it is miserable in predicting what may happen in the next weeks or months. An FSH level may come back 40 (suggesting menopause) on one day, but you may ovulate 6 weeks from now at have an FSH at 8. It's really only over time that you really can better understand if this is the ‘new norm’ or transient. Perimenopause is known to have fluctuating symptoms; once in menopause, most women's symptoms are more predictable.

To make sex comfortable again, I would start with a lubricant. I would try a water-based lube like Carrageenan or Yes. If using a lube makes you comfortable and doesn't irritate the area, that can be a great, simple solution for now.

A warming lube can add some additional sensation for arousal and make orgasm somewhat stronger. Try Oceanus G Stimulating or Sliquid Sensations. Occasionally the warming lubes can be irritating if the area is sensitive, which is why I'd start with a non-stimulating water-based lube; then test a small amount of the warming lube to see if it works for you!

Good luck! I know you can have satisfying sex again.

The Sensual Grandmother?

For the first 10 or 15 years that we knew her, we were not to call Elaine “Grandma.” At least and especially not in public. She was too busy attending to her coiffure and hosting wild parties for the American film productions in Rome to acknowledge this shift in her life. Holly GoLightly at the age of 55, she did not orchestrate or ask for grandmotherhood, so why should she assume the title?

Elaine is a footnote to this post, so let’s back up a bit.

It’s supposed to work this way:You have a baby, and your whole life changes forever. You prepare carefully, but nothing can quite ready you for motherhood. It shakes you up and places you down in another realm of life entirely. Your role as mother now trumps all the other roles you play. And all your family, friends, and neighbors understand, are happy for you, and supportive. Because we know what a mother is. Right?

But how is it supposed to work when your child has a baby? The shift in your roles is just as momentous, really, but less understood by everyone around you, and also by our ever-changing culture.

Sunday is Grandparents' Day, and we thought we’d take a minute to ponder this change in identity that comes along, for many of us, close on the heels of menopause.

My girlfriends are going through this identity shift now. But I remember listening in when my mother and her friends became grandparents. They advised and consoled one another daily. For them there was anguish in being sidelined, or demoted. They expected to be involved, but they were not. Distance was the word of the day. The mom role, the central role of their adulthood, was somebody else’s job now, and being demoted while still in the room is nothing but awkward. That problem alone can be stunning (stun-gun set on paralysis).

This distant role was completely different than the role many of their grandmothers played. And our grandmothering will be very different from our mothers’. We just don’t quite know how yet. We are writing our new job descriptions on the job. Grandmotherhood will be whatever we make of it, shaped by family dynamics not entirely in our control. It can become the central role of your life, an enriching extra dimension. Or you can pull an Elaine, and pretend it never happened. (Her grandchildren thought she was fabulous, by the way.)

Our new role will need to encompass very well-developed mothering skills, fit bodies, pretty darned agile minds, and a new phenomenon for women our age: A lot of us are still enjoying just being girls. You know, being fit, fashionable, fabulous, garrulous girls. We are not prepared for the invisibility cloak that has long been the costume for the role of Granny.

I’ve had friends in tears, wondering whether they should cut their hair off and get a perm? Should they start wearing stretchy pants? Certainly no grandma should wear a thong anymore, right? And spikey heels are just… gross for grandma. Or are they?

These may not seem like pressing or important questions at the moment of bringing a new life into the world, a new generation into your family, but they represent a complete emotional upheaval. We’re moving into the upper ranks of our families. The end is not near, but you can see it from here. It’s awful at the very moment when everything should be wonderful. It's emotional quicksand. Even the most stable among us can get trapped in it.

So. Got a girlfriend who’s a new grandmother? Our advice is: Pamper her. Make coffee dates, and give her your ear. Listen and attend as she carves out her own philosophy of grandmothering. This might be you some day. And then come back and tell us about what grandmothering means to the girl in you, will you? We would love to hear about your experiences.

To mark the day, we've developed a few special Grandma’s gift sets as a comfort and assurance for a grandmother in your life. We hope you like them--and she does, too.

Happy Grandparents’ Day!

When Was the Last Time You Used a Condom?

It's a personal question, I know, but one I'm trying to be sure to ask my midlife and older patients who are newly single and sexually active.

Among women our age, sexually transmitted infections (STIs, sometimes called STDs for sexually transmitted diseases) are up and condom use is down. There's a direct correlation.

Those of us who have spent the last 30 to 40 years in long-term monogamous relationships may not have even seen a condom in that time, let alone bought and used one. When contraception was the goal and a steady partner was the norm, we tended to choose less intrusive methods of protection--like the pill or IUDs.

Now, though, if you're single and entertaining the possibility of a new sexual relationship, it's time to get acquainted or reacquainted with the most effective means of preventing transmission of STIs like gonorrhea, HPV, herpes, chlamydia, and HIV: the venerable condom. Because it's an actual physical barrier, and because it's the easiest barrier to use, it's the most effective option we've seen.

Of course you can buy condoms at your local drugstore or grocery store, but if you don't want your kid's best friend waiting on you, you may want to consider an online source. And if you've never bought or used latex protection before, don't worry. We've sought out the right combination of function, fun, and discreet packaging so you can purchase from the comfort (and privacy) of your laptop, and our website offers basic instructions for using condoms.

(A parenthetical note: We know there are female condoms, which work just fine as a barrier for protection. But when we actually tested them as part of our product selection, we found them too clunky for us to be comfortable. We wouldn't recommend them to our friends. But we'll keep an eye on the options and let you know when something better comes along--or let us know if you've found a brand or a method that makes them your preference.)

A few more tips to help build your condom confidence:

-- Keep a ready supply on hand--in a zippered pocket of your purse, in a drawer of your nightstand, or in nifty bedside storage like this tissue box we found with a private drawer. Scrambling around for that little packet in the heat of passion can cool things down in a hurry.

-- Talk with your partner about condom use as soon as it seems clear that sexual intimacy is a definite possibility for the two of you. Agreeing that protection is essential--and deciding who's in charge of making sure it's there when the time is right--will ease anxiety and embarrassment for both of you.

-- Incorporate condoms into your sex play and lovemaking. Application can be quite exciting in itself!

Finally, remember that not even your friendly condom offers 100-percent protection. In addition to insisting on a latex condom, NAMS (North American Menopause Society) guidelines for safer sex include choosing partners wisely and discussing sexual histories, getting an annual exam that includes testing for STIs, and making sure that your Hepatitis B vaccine is up to date.

Q: What birth control should I consider at 49?

This is an important issue. At 49 you are ‘subfertile,’ but not infertile. You also can’t rely on rhythm, as there is no rhythm!

Barrier methods--condoms or a diaphragm--can work well, although they take some anticipation and planning. (If you're in a new relationship, you might also consider the protection condoms provide against STIs, too.) If you choose that route, intravaginal spermicides in combination with the barrier will give you some additional coverage. The birth control pill, which is approved for use until age 55 or menopause, can still be an option. If you did well on it in the past, you would likely do well on it again; a careful health history would help make sure you are a good candidate. Now pills can be given in such a way that you menstruate much less often, or not at all. And one more option: There is an IUD on the market that lasts 5 years--likely to get you to menopause.

What you choose depends on your health history and your personal preferences. I'm glad you're both enjoying your sexuality again and paying attention to this issue!

In Search of Hot Lit

We’ve written before about our efforts to find erotica to recommend to our growing MiddlesexMD community (Hi there, community!). Our efforts are are purely pragmatic, you understand. By subjecting ourselves to hours of film, reams of erotica, searing our eyeballs with the online offerings — all off this sacrifice, all for YOU, we are looking to find the good stuff, the stuff that really does, in fact, heat up a grown woman. (Real life experience has a way of turning an awful lot of porn and romance into comedy, we have found.)

If you haven’t been following the posts here, let me explain briefly: In menopause, our circulating sex hormones dimish. That can sometimes, not always, lead to a drop in libido. Even when the libido is willing, becoming aroused enough for sex can take a little time and effort. We need to step in, do the work our hormones did for us when we were young.

An easy and inexpensive way to adjust to this new reality is to give ourselves more opportunities to have sexual thoughts -- i.e., watching sexy movies, reading sexy literature, masturbating, wearing/doing sexy things.

Sexy literature… That's my subject. I've been poking around just a bit, looking at collections of erotica, some of it good fun, much of it yawningly dopey. While I’ve been looking, I’ve been thinking about the guideline we established during our silly, foiled movie night: We much prefer a Great Story That is Sexy to a sex story.

Enter Jacqueline Carey. When I think of great stories that are sexy, she springs immediately to mind. Her New York Times bestselling Kushiel’s Legacy Series encompass great epic tales full of romance, politics, turmoil, grief, tragic loss, breathtaking triumphs, and plenty of sex. Most of the sex is great, some of it is frightening, but all of it is integral to the storyline. I love that. Her novels are fat and involving enough to keep me diving into them night after night. Sexy enough to keep me on the edge of my libido for hundreds of pages.

So, why not ask the author herself about “Great Stories that are Sexy”?

I put the question to her, and waited. At first, coming up with a list stumped Carey too, which made me feel a little better about coming up with so few recommendations of my own. She's trolling for answers among her friends, too, but did come up with a starter set. Ms. Carey says:

*Try Diana Gabaldon's "Outlander" series.
*For fun, sexy fluff, Janet Evanovich's "Stephanie Plum" series.
*I don't know how well it stands the test of time, but I thought Colleen McCullough's The Thorn Birds was hella sexy and a good read back in the day.
*And check out Smart Bitches, Trashy Books for romance reviews. The genre's come a long way in the past decades.
I feel as if we've finally got a foothold on Hot Lit. The birth of a canon. But it's not really very big, is it? We need to feed this list. And for that, we need to hear from you. What do you think? Have you found writers whose work does it for you? Please share. We will keep adding to the list and will republish it as it grows. Those of us who read constantly need a steady supply…!

STIs--Not Just Your Daughter's (or Granddaughter's) Concern

She's 54 years old. She's spent most of her adult life in a long-term monogamous relationship. She's just been diagnosed with genital herpes.

This happens more often than you might think.

Even I -- who should know better! -- have been guilty of age bias when it comes to testing for sexually transmitted infections (STIs, also called STDs, for sexually transmitted diseases).

In my former practice, when a 20-year-old came in presenting with symptoms (discharge, discomfort, irritation) that might indicate an STI, I would automatically screen her. When a 50- or 60-year-old came to me with the same symptoms, I was more likely to ask before I tested: "Is this a possibility?" If she said "no," I tended to trust that. I was trusting my patients. They were trusting their partners.

Times have changed.

Over the past decade, STI rates among people 45 and older more than doubled. In April, the Centers for Disease Control and Prevention reported that senior citizens accounted for 24 percent of total AIDS cases, up from 17 percent in 2001.

Researchers point to climbing divorce rates at mid-life, the rise of online dating services, the increasing number of men availing themselves of treatment for erectile disfunction. And all of these are contributing factors, I'm sure. But in my experience, the most likely cause of the up-tick in STIs among women past their child-bearing years is lack of awareness and prevention.

If you know that pregnancy is not a possibility, why use a condom?

Unfortunately, the risk of contracting STIs -- including syphilis, gonorrhea, genital herpes, HPV, hepatitis B, and HIV -- does not end at menopause. In fact, sexually active postmenopausal women may be more vulnerable than younger women; the thinning, more delicate genital tissue that comes with age is also more prone to small cuts or tears that provide pathways for infection.

And -- it's not fair, but there it is -- with almost every STI, exposed men are less likely to experience symptoms, simply because they don't have the equivalent of a cervix and a vagina and the skin of a vulva. The kind, older gentleman who gave my 54-year-old patient genital herpes might honestly not have known he was infected.

These days, when a 50-or-60-ish woman shows up in my office with symptoms that point to a possible STI, I go ahead and screen. I'll say, "I understand this is not a likely outcome, but I want to make sure I'm checking all possibilities."

Worry about STI can be a real drag on sexual enjoyment. We'll talk about what you can do to insure that contracting an STI is not a possibility for you in my next post: "When Was the Last Time You Used a Condom?"

Q: Could thyroid problems affect my ability to orgasm?

Thyroid disorders are not typically a significant factor for libido or orgasm. A bigger issue is expectations: The majority (probably at least 80 percent) of women cannot have and never have had an orgasm with intercourse alone. Most women need more direct stimulation. As we get older and in the absence of estrogen, having an orgasm without direct stimulation becomes even more difficult. It may not be realistic to expect to have an orgasm with intercourse or penetration.

A vibrator can be a great addition for that direct stimulation. You might want to try one with a warming lubricant, and see what happens! The Gigi2, Liv2, and Siri2 are three options we have offered at MiddlesexMD that have more intense stimulation than some others on the market. I have seen some amazing results from women who hadn’t had an orgasm in years because of medications that interfere with orgasm or medical conditions that make orgasm more difficult. They were successful using these products, so give it a try and good luck!

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