I live and practice in the Midwest, where open discussion about sex is just not part of the culture. Even among close-knit groups of girlfriends, it’s a rare discussion, at least not past a certain age. I’m trying to remember when I stopped talking about sex openly with my friends...
I remember it was a subject of great interest and fascination when I was very young. Whispers, conjectures, a lot of mis-information and tall tales. By high school, we knew more, the better informed among us bringing along the uninformed. In college, we received a great deal more detail as data from actual, rather than fictional, experimentation became more commonplace.
I suppose it is marriage that closes our mouths. We may have been willing to share exploits or guess at sex before we chose our mates, but once we do, the walls of privacy go up, and silence rules our sexual lives.
And that’s okay, so long as we have opportunities to continue to learn and explore, and provided we have some source of information and aid when things aren’t working. Because, let’s face it, we aren’t trained in sexual techniques. There is no sexual master class. No black belt to earn. And sex isn’t always smooth sailing. Our anatomy isn’t flawless or consistent in its function. We need information as we grow and change sexually, and most particularly when we enter the menopause.
In some cultures discussion about sexual technique among same-sex family members and social sets is nearly endless. But in our Puritan-influenced culture, silence is golden. So what are we to do? It isn’t likely that we’ll change a whole culture any time soon.
Well, online, we have a real opportunity. Here, we can talk to and learn from each other without sacrificing the privacy and propriety we hold dear. The online environment we want to build is one where we can share reliable, well-researched information that will help us understand and share not just matters of sexual health, but of sexual technique, too. A good, safe, monitored discussion place to learn from each other and from the research and writings of sexual health practitioners.
We are busy gathering a good collection of information, but we’ll want to hear from you, too. What has changed for you with the menopause? What questions do you have? What has worked for you? What have you learned from others? What experiences are daunting? What Aha!s can you share? Post under your own name, or under another name you choose -- either way, we'd love to hear from you.
The post title is just tongue-in-cheek, folks. A little health writing humor, poking a stick at the whole idea of health “secrets.”
We don’t believe in keeping information about attaining good health secret.
So here, today, long before going live with our website, we are happy to divulge our recipe for sex after menopause. The ingredients are:
Tada! Whooot!!! We have balloons falling and confetti rising over here at MsMD headquarters!! How about you?! No?
Maybe you don’t realize how hard it is to distill good-sex-after-menopause down to an easy-to-remember system? So let me explain: Months ago, we began our work with a hard look at the American Psychiatric Association's DSM-IV description of disorders contributing to Women’s Sexual Dysfunction (There’s a phrase we won’t use a lot around here, because it worries us. If we don’t yet understand Women’s Sexual Function, how can we comfortably describe its dysfunction?).
We embraced (and strive to remain mindful of) the point of view of women’s sexual problems developed by the New View Campaign, and their concerns about the medicalization of human sexuality. We reduced by our focus on peri-menopausal and menopausal women. Filtered all of these concerns through recent research and publications by members of the North American Menopause Society (NAMS) and the International Society for the Study of Women’s Sexual Health (ISSWSH).
We surveyed current literature on female sexuality. We added recent work by sex researchers and therapists and coaches, relationship coaches and mindfulness gurus.
That was the first step.
The next step was sorting all of the helpful advice, tips, skills, and learning into clear descriptions of conditions and pragmatic actions so that women in menopause can understand exactly what is going on with their bodies and what they can do about it if they want things to be different.
We didn’t go looking for the recipe. It surfaced from the work, organically. We began to see how all of the latest and best advice of medical, psychiatric, and sex researchers and coaches, seeking to help older women enjoy their sexuality, clustered into just a few central goals. What does a woman need to do to enjoy sex after menopause? (Assuming, of course, that she wants to enjoy sex after menopause at all. Because that is still her choice.)
She needs to know the physiology of menopause, so she understands what is happening when it happens, and especially that though her experiences are unique to her, she's not alone. And she needs to know some new sexual techniques that will keep sex enjoyable as she ages.
She needs to learn how to take care of her vulvo-vaginal tissues so that sex remains comfortable.
3. Pelvic Tone
She needs to learn how and why to strengthen and maintain her pelvic girdle to encourage circulation and maintain or strengthen her orgasms.
She needs to compensate for less blood flow and less sensitivity in her genital tissues by providing herself with more stimulation, more sexual sensation.
She needs what every woman needs at every age for sex to be good. Sex needs to be intimate. It needs to mindfully create and reinforce a real connection. There it is. No secrets. When we take our site live in April, you’ll get all the rest, descriptions of conditions that get in the way of achieving these five goals, actions you can discuss with your doctor or take on your own to enjoy sexuality for life, and products we have selected to help you on your way.
MiddlesexMD began with a business plan I wrote for my Masters in Medical Management program at Carnegie Mellon University. Its essential proposition — offering women over 40 the information, advice, and products they need to sustain good sexual health as they age — is all there in my original paper.
Taking a business from paper to reality takes a lot of work, and skill, and putting in hours doing things you might not have ever pictured yourself doing. But in this life, a woman’s got to do what she’s got to do to get it all done. Right?
I was lucky enough to find the right business partner, a woman I like and respect who has impressive business credentials, is reaching midlife herself, and understands the need for better information for women of our generation.
So when she suggested, early in our business planning, that we head to a trade show for sex products, both to shop for appropriate products for menopausal women, and to learn about the industry, I took a deep breath, and swallowed hard. She knew it was the right thing to do, and I knew she knew what she was talking about.
So off we went to the AVN Novelty Expo in Los Angeles. Three days of product and toy makers hoping to entice buyers from all of the big sex stores and distributors. Thousands of people familiar with the trade and the spectacle and the atmosphere of the Los Angeles sexpo… Plus the two of us: A gynecologist from the Midwest and her friend, the corporate exec.
We stayed close to each other as we breezed past the signs suggesting we had to be over 18 to enter the show. And, you know how it is, waiting for your eyes to adjust when you’ve walked into harsh lighting after being in a low-lit room? At first you blink a lot, but before long you can make out where you are?
I suppose going to this show for the first time was a bit like that. We spent the morning blinking, remembering to breathe, feeling a bit jumpy. But after a while, our agenda kicked in.
What surprised us more than anything was the prevalence of really poor quality products made of questionable materials, with no warranty, yet made to be used inside the body. As a doctor, that’s a little hard to see.
But among all the thorns there were really great products too, ones designed with health and durability and a great experience in mind. And products with smart, dedicated people standing behind them. We found all of those that we could.
By the afternoon it was easy for us to cruise down those aisles and aisles of multi-colored, throbbing, bobbing, moist, flavored, leather-covered, studded, and hinged things, to find the exact products and people we needed to meet.
-- A guy who developed an organic line of glycerin-free and paraben-free lubricants because his wife was allergic to everything on the market.
-- The woman from the UK whose target market was menopausal women, her products developed to function exactly as we need them to.
-- Companies whose sexual aids are designed by thoughtful designers, in beautiful, tactile materials. These aren't toys. They're objects so lovely and well-made anyone would want to own them.
My partner was right. We did need to see that show. We learned what we needed to know and found what we needed for the store faster than we could have sitting at home with our search engines.
We have pulled together a really nice collection of products, spanning price ranges and functions. We'll be able to show you the results of our shopping expedition in April, when the site is ready. Meantime we'd love to hear your questions, advice, and experiences in finding and using the products that work for you.
Since launching MiddlesexMD, I have to say, my dinners have gotten a lot more spicy.
You know how it is when dining with buddies. It’s polite—required—for them to ask what you’ve been up to lately.
When I tell them about MiddlesexMD, you would think it might stop the conversation cold, but I’ve found just the opposite is true.
My friends do want to talk about this. It’s not surprising when men are there that they are a bit more quiet, but they are engaged, too. We all appreciate our partners’ attention to these discussions—because we’re not always alone with these changes. They affect our sexual partners, of course.
I had dinner the other night with an old friend. The subject of our conversation turned to the idea of how important it is, especially for long-partnered people, to keep their sexuality top-of-mind if they want to keep their sex life going. I talked about how older women, particularly, need extra stimuli (both physical and emotional) as they get older.
We need more opportunities to think about sex, consider it, fantasize about it, and more emotional intimacy throughout the day to find or sustain the mood. Sex is like any pursuit, if you want to get better at it, it requires your attention. Some call this "work" Awareness or Mindfulness. And I think this dimension of a relationship is valuable enough to “do the work.” (Smile.)
It was a simple conversation. I didn’t think it had any sort of profound effect at the time. But I ran into that friend a few weeks later. She pulled me aside, and whispered, “Hey Barb! Thinking about sex more? It WORKS.”
I wasn’t surprised, if it works for me, it should for you too!
Gee, I love my job.
Writing for my gynecologist friend has included a lot of Aha! moments. I admit some of this learning makes me blush. It's not just because I blush when talking about sex—though I do. It's because I’m embarrassed when I’m caught not knowing things I think I should have known a long, long time ago.
So, I’m reading along in Dr. Barb’s enormous textbooks on female sexuality, when I come across an illustration of the clitoris, sort of like the one below. I nearly passed it over, because, what’s to know at my age? I've lived with this equipment for 50 years. I'd like to think I know my way around it.
But this illustration colored in the entire structure of the clitoris. Not just the glans, but also the shaft and the crus clitoris, or crura.
Excuse me… the shaft?... and the crura?
No.. please picture me picking my head up like a prairie dog, looking around my office, and asking the air...
"And the crura!?!”
Somehow in all my curious, bookish, research-happy past, I never learned more about the clitoris than about the little button—the glans—the part that sticks out from the prepuce at the top of the labia.
Who knew my clitoris had legs? And a shaft, even?
But yes, indeed. It's practically a little penis under that hood. With long, long legs that extend waaay back toward the perineum, which fill with blood when I’m aroused.
Now, of course, the cool, rational part of my mind tells me I have enjoyed my crura—and possibly even the shaft—because they’ve been there all along. But I would have liked to know about them from the start. I can’t help but wish for a few years back in which I could quite clearly visualize my long, leggy crura.
What can we do with this information? Well, with age, the clitoris loses some sensitivity. We may find it useful to use warming oils and gels or vibrating sex aids to increase stimulation to the clitoris as we prepare for or engage in sex.
And of course, to do that, it really does help to know where it is.
Back to the books...
...and why you should care too!
It began when I partnered with the local hospital in my hometown to evaluate local women's health services, looking for any gaps where additional services were needed. In the process, it became clear that our community needed and could support a healthcare practice devoted to the special needs and care of women who were past their child-bearing years—these special needs were largely ignored by existing providers.
I decided to transform my practice. That was 4 years ago. I studied and became certified by the North American Menopause Society as a menopause care provider, and while welcoming patients into my practice, used their questionaire—a thorough document that makes it easy for new patients to give me a comprehensive view of their symptoms and health histories. On that eight-page-long form there are just a few questions for women to answer about their current and past sexual experiences:
Well, I was amazed by the responses from my new patients. 60 percent of my patients have experienced a loss of interest in sexual activities, 45 percent have a loss of arousal, and 45 percent a loss of sexual response. And when I talked to them, they were:
And when you carry those numbers from my practice to the rest of the country—well, more than 44 million women are aged 40 to 65 in the US alone. Some 6,000 of us reach menopause every day. And at least half of us experience sexual problems with menopause. Probably more.
That’s a lot of disappointed women. And a lot of disappointed men too… I believe there can be more, and women don’t have to just accept the changes if they don’t want to. I see MiddlesexMD as a real caregiving opportunity: Make it easy for women over 40 to gather the information and products they need to sustain their sexuality after menopause.
And that could make everyone happier!
Menopause brings a drop in circulating estrogen. And a drop in circulating estrogen often (but not always!) brings a drop in sexual response. So at midlife, for many of us, sexual satisfaction takes more—more time, more moisture, more sensation.
I like to use the reading glasses analogy. When you reach 40, suddenly it’s not easy to read the fine print. When that happened, did you give up reading? Of course not. You got reading glasses and went on. Or bifocal contacts. You adjusted.
Many of my patients have little to no experience using sexual aids. I may recommend that they consider using a vibrator or a lubricant or a positioning pillow—but they have to actually purchase these things. I can just picture my patients walking out of my office and shaking their heads at the thought.
A majority of my patients are not going to visit a sex shop. They are not likely to be comfortable or happy visiting the sex shops online either. I looked and looked for a good place to send my patients, where the focus is on sexual health, on sustaining our sexuality. We need a safe place to shop, where the products are durable and made of safe materials. And frankly, we need a place that doesn’t cast women as sexual toys, and that acknowledges a healthy sexuality for people over 40.
My patients are from a generation of women who have redefined female sexuality, and are now redefining menopause. As pioneers, we all had a lot to learn, and still do. Many of us have never used sex toys or lubricants at all. The language of these products is completely foreign to many of us. We can learn from and teach each other.
So I'm trying to build a sexual support site for us. And that includes a product store for us. A store that’s comfortable, private, but has the advantage of including guidance that will help women who are new to this language choose products that will make sense for their own sexuality, their conditions, their goals.
We won’t offer hundreds of items. We will keep the information informative, tasteful, and clear. We’ve been working hard (no, really) shopping, testing, choosing, sorting—pulling together a portfolio of products specifically for midlife women who want to enjoy sexuality for life.
I can’t wait for you to see the selection. And when you do, please share your thoughts. I very much want our product selections to be influenced by our customers and the menopause community.
Hi everybody. My name is Julie. I’m a writer here at MiddlesexMD. My credentials for writing about sex at midlife are… Well… I have reached midlife. And I enjoy sex.
Despite almost 30 years of togetherness with the same guy. Despite aches and pains, stress and too little time, and all the physical surprises of menopause. Despite all of that, we are nowhere near ready to hang up our sheets.
So when my own friend (we served undergraduate years together) and doctor (my own menopause doctor, because I’m lucky), Dr. Barb, asked me to help her develop her website, I jumped at the chance. I needed to learn about this myself. What better way?
I’ve been writing for years and years, and for many years researching and writing on health topics. But I have never written about sexual health. Barb is teaching me—you would not believe the size and density of these textbooks.
So, day one, lesson one, Basson’s Model. I had no idea that there is a difference between Sexual Desire and Sexual Arousal. I really always thought they were the same thing, or flip sides of the same impulse, or something. Because that’s the way I’d experienced it for most of my life. Arousal and Desire arrived on my doorstep, it seemed, instantaneously.
But they are considered distinct aspects of the sexual experience. And now that menopause has slowed me down a bit, I understand better.
We can achieve arousal with or without desire. We can have comfortable, enjoyable, emotionally satisfying sex with or without desire. That is, we need arousal for sex. But we don’t need desire. We like it. We want it. We enjoy it. But we don’t need it to engage in sex or get a lot out of our sexual experiences.
The easiest way for me to tease these ideas apart is this way: Desire happens in your head. It’s an idea. Arousal happens all over. It’s physical. Certainly the idea can spark a physical response. But it works the other way more often for women. Sexual stimuli—physical sensations, emotional feelings, sights, sounds, smells—arouse us physically. Our arousal readies our bodies for sex and can breed desire.
So, when we start talking about the kinds of sexual problems women may experience with menopause, the distinction becomes very important. Are we having difficulty with arousal or with desire? Or both?
What used to follow automatically from sexual stimuli—the arousal part—may now take more time and more stimulation. We may have to ask for and give ourselves more help and support to become aroused. This isn’t a lack of desire, but a greater need for stimulation.
We may be receiving all the same sexual stimuli that we always have, that always worked before, but we don’t respond to it as readily. We love our partners just as much or more. But our bodies just don't respond as quickly now. Or we may now have physical or emotional limitations or illness or medications that muffle the effect of sexual stimulation.
This was lesson one for me. A real eye opener. I used to worry that I didn't feel the same desire as I did when I was in my 20s and 30s. Worry isn't the word. It upset me. I am much more relaxed about it now. I'm learning to tune in to stimulation, to appreciate and notice my body's response more. And that helps a lot. Well, I suppose writing about sex every day doesn't hurt either...
There have been and will be many more lessons. Some embarrassingly basic. Some I wish I’d known 30 years ago. I will always be willing to show my ignorance in these matters, followed by Dr. Barb’s patient teachings.
Meantime, I’m gathering up all my favorite stimulants: I’m with Reka, a visitor from the last post, on the potency of Dr. Gregory House. And Dr. Andrew Weil too (his relaxation tapes have an opposite, unadvertised effect on me). I have a thing for David Strathairn. Indian food. Tango/dance movies. And I have this special drawer in my bedroom…. And you? Care to share?
(Anonymous sharing is always welcome. Or make up a name, if you like!)
Rosemary Basson's model of female sexual response
The science of human sexuality is young. For most of the last century, we assumed that men and women approach sex in roughly the same way.
I know: Crazy. But as I said, the science is young.
Older models (Masters & Johnson, Kaplan) theorized that sex for people happens in a few neat, linear stages, beginning with desire, proceeding next to arousal, then orgasm, and finally satisfaction.
But it doesn’t always work that way, particularly for women, and especially for women over 40.
More recent researchers who focus on women’s sexuality, confirm that really, women do not experience sex in this simple, linear way. We sometimes skip phases. Our reasons to have sex are many and often complex.
We can be perfectly satisfied with sex that does not include orgasm, and we can reach orgasm without desire. We are flexible that way.
Enter Rosemary Basson, MB, FRCP, of the University of British Columbia. Basson formalized a new model of female sexuality that is now widely accepted.
She offers two key insights. First: Female sexual desire is generally more responsive than spontaneous. That is, we are more likely to respond to sexual stimuli — thoughts, sights, smells, and sounds — than we are to spark an interest in sex out of thin air (Men, on the other hand, specialize in this).
Another key insight: emotional intimacy matters to women. I know, that doesn’t sound like a news flash, but in the realm of the biological sciences, it’s news, trust me.
So Basson drew a new model – not a linear series of steps, but a circle that includes both sexual stimuli — the thoughts that trigger a woman to take an interest in sex, and emotional intimacy — the emotional payoffs of the experience that lead her to want to come back for more.
I love Basson’s model and use it every day in my practice to help my patients understand how sex really works for us.
We need to understand that it’s okay and it’s normal that we don’t always start with desire. And as we enter menopause, and our hormone levels drop, spontaneous thoughts about sex, and responsiveness to opportunities for sex diminish for most of us. That’s natural and normal too.
If you don’t like the situation, and you want to feel more sexual, more responsive, Basson’s model gives us the hint: We need to stimulate our minds. The more sexual stimuli we receive, the more sexual we feel.
So, this is worth thinking about today, a worthy discussion to have with your partner: What makes you feel sexy? A juicy romance novel? A James Bond movie? Erotic art? Pretty underpinnings? A romantic dinner? Having your partner empty the dishwasher? Spend some time thinking about that. Maybe make a list. And then provide for these things. Sexy is as sexy does, friends.
And, hey, if you’d like to help a sister find some sexual motivation, use the comment field below to share. What sights, sounds, scents, scenes help you get in the mood?
A big bouquet of roses waited for me at the front desk of my clinic.
It wasn’t my anniversary or my birthday. And doctors just don’t get a lot of flowers. When I saw who sent them, I smiled that special “good sex” smile, even though the sex I was smiling about wasn’t my own.
I've been a women's health doctor for more than 20 years, focused on midlife women for the past four. These flowers were not from a new mom or a patient with a difficult disease. These came from a patient who got her sex life back.
That may not seem like a big win in the scheme of things, but it was a wake-up call for me. My patient, now in menopause, was distraught that her sex life seemed to be over so soon—too soon. Sex was effortless for most of her life. It had been very satisfying. And suddenly, it wasn't any more.
We talked about sexual response with her hormonal changes, all of the many factors that could be influencing her experience. Then we talked about her options for managing these changes. She tried different routes, but when I introduced her to a device—she had not used them before—that made the difference for her. With the help of a simple tool, she was able to adapt to her new reality, and enjoy sex again.
It was a fairly straightforward doctor-patient exchange, but not a common one. Women rarely talk to their doctors about sex. As a menopause practitioner, though, I know that changes in sexual response are a key source of distress for a lot of women and their partners at this age.
Is it a doctor's job to help their patients have good sex? I think it is, absolutely. A healthy sex life sustains our overall health and well-being. Sex is good for us, and helps us to remain vibrant and strong. Menopause isn't a disease. It's a natural process. The more we understand this process, and discuss it openly, the easier it will be for us to make adjustments to accommodate our bodies' changes.
The roses were evidence that my patient's sex life had been restored. How many women like her have never raised the question with their doctors. Their gynecologists? Or sisters? Or friends?
Natural changes during meopause can make it feel like the door is closing on your sex life. For some of us, that’s not a huge loss. For others, it’s seriously distressing.
But these changes don't have to stop your sex life. They will certainly change things a bit. They may require learning some new things, trying some new techniques, experimenting with a few products.
I'm working with my friends to launch MiddlesexMD. We will reach out to women like my patient, women at midlife who aren’t ready to close the door on sex, and who aren’t sure how or when to talk with their doctors about their experiences. My partners and I want to build a trustworthy (and bouquet-worthy!) sexual health resource for midlife women, combining helpful advice, clinical expertise and a carefully selected set of products with a record of helping women continue to enjoy a satisfying sexual life as they age.
By launching our blog first, we're starting the conversation. We'd love to hear what you think, need, want. What do you think about a website devoted to midlife sex? Can you relate to the changes in your sex life? Please leave a comment to join the discussion, and/or sign up to receive the posts by email.