MiddlesexMD

Alive! Alive-O!

A story is necessary to bring about the appropriate emotion...

When I was in my early 40s, I decided I needed to run a big race. Not so much a long race, but a big one, with crowds and a chip on my shoe and a finish line and a medal. A real race. At the time I was pretty heavy, but working on getting leaner, and putting a big race out in front of me seemed a good goal. Something to look forward to, and a kind of capstone to all the hard work of losing weight and getting fit.

As it happened, the perfect race would be run in Dublin at a time when I planned to be in Ireland anyway, riding in my husband’s bags as he went there to teach for one lovely month of May.

This race is an annual 8K, dubbed a mini-marathon, run entirely by women, and doubles as one of the biggest fund-raising events in Ireland every year. That day 40,000 women gathered in the center of the city to await the starting gun. Tradition dictates that  all these women together sing the first verse of the old Irish folk song, Molly Malone, just before the race starts...

This makes absolutely every woman in the field begin their run with tears streaming down their faces, and feeling the ghost of Molly in their hearts, and feeling very much alive. I haven’t quite felt so glad and proud to be alive and kicking as I was that day.

Until today. Because tomorrow, MiddlesexMD.com goes live. We’re all thrilled and a little terrified, waiting here, at the starting line. This blog has been a bit quiet for the past month as we’ve all been hurling ourselves into our final wind-sprints. This is an amazing group of experienced, wise, and funny midlife women who have worked hard for a year now to pull off Dr. Barb DePree’s dream of a smart, informative, trustworthy place for women in menopause to explore and sustain their sexuality for life.

And it has been a dream project. Important. Fascinating. We have learned so much, and look forward to learning so much more. Learning from you, for you, and making all the necessary connections that women our age need to keep feeling Alive! Alive-O!

Please take the time to take a peek soon, and tell us what you think!

Seeking Worthy Erotica

As a general rule, women over 40 need more stimulation to become aroused enough for good sex. When we were young, just thinking about making love with our partners may have been enough to arouse us physically, but as we grow older, as sex hormones decrease and distractions build, it takes more. But not too much more. For some of us, reading a steamy novel will do it. For others, visual stimulation works better. A hot movie, for instance.

Ever since I first conceived of MiddlesexMD, one of my goals has been to gather a tasteful collection of erotica, visual and verbal art that will stimulate arousal in older women. All we had to do is find it, right? How hard could that be?

None of us at MiddlesexMD had really explored the world of erotic art. So we set our product buyer to work, buying up a sampling of the “state of the art,” beginning with films. She studied and chose a good selection, from how-to films to soft-boiled, story-centered erotic movies. We chose films targeted at women. And films targeted at older women. As the DVDs piled up in our product room, we decided to take an analytical approach to our selection.

Sort of analytical. We each invited a few girlfriends over for glass of wine, a viewing and a discussion.

Our goal was to review these films to gather criteria and characteristics of films that most appealed to our friends — some way to inform our buying choices for the store.  Which would they use? Which would they recommend to their friends or watch with their partners? How would they rate them? What, specifically did they like about each? We had our notepads and our pens poised. We had poured the wine, curled up in front of the TV…

And then, showtime!

One film after another… fell flat on its face. We couldn’t watch more than a minute or two of any of them without reaching for the eject button. There was no analysis, no rating, no pulling apart criteria. We all… hated everything about all of them.

And we were disappointed. Really? Does it all really have to be so awful? We began again, discussing scenes in mainstream movies that we love, that work for us.  We could easily name dozens of scenes that made us blush just recalling them. Scenes from the English Patient, Room with a View, Breathless, Nine and a Half Weeks, Body Heat, The Piano, Atonement, Shakespeare in Love, The Unbearable Lightness of Being, Looking for Mr. Goodbar, The Godfather, Sweetland, The Graduate, Under the Tuscan Sun, Thief of Hearts, Vicky Christina Barcelona, Moonstruck, anything with Daniel Craig in it. We exausted ourselves thinking of the scenes.

And what characteristics did these movies and scenes have that mattered to us? The story is important, the emotions feel real. There is a buildup of passion, tension, and release. The woman’s seduction receives detailed attention. In short, there is romance.

What we didn’t like? Explicit sex. Mechanics. We really enjoy using our imaginations to fill in, and are perfectly happy with closeups of rapt faces.

We learned a lot from each other that night. We learned, too, that among our friends, at least, we’d all rather read a good sex scene than watch one. So now we’re looking for really good erotica to offer in our store.

How about you? Have you found tried-and-true erotica that works for you? What do you like about it? Have you failed to find anything? What is it about the works you’ve tried that doesn’t work for you?

Vaginal Patency for Single Women

A lot of the patients in my menopause practice are single women. My patients who have no sexual partners can be quick to dismiss my questions about sexual symptoms, figuring that without a partner in their lives, they have no sexual concerns. I have two worries about that.

First, you don’t need a partner to have orgasms. Self-satisfaction is good for us physically and mentally. As a doctor, I often encourage women to consider this, particularly older single women, because of the health benefits.

Second, self-stimulation helps us maintain patent vaginal tissues.

My friends would like me to point out that “patent” is a term doctors use when talking about tube-like structures. Patent means “open.”

Maintaining patent vaginal tissues means making sure your vagina remains open, usable, in case one day you do find someone worthy of a sexual relationship.

If you have lived with your vagina for 40 years without giving it much of a thought, you should know that its patency has been maintained largely through hormonal influence. Now, as estrogen declines, particularly if it declines abruptly (as it does in surgical menopause), the tissues of your vagina will become thinner and more fragile, and circulation to those tissues will decrease.

If your vagina isn’t receiving any stimulation, those changes will happen more quickly. The more you use your vagina, the slower the changes go. When we say “Use it or lose it,” this is what we mean.

I have met plenty of patients who did not know that vaginas need to be maintained. When you can't see the vagina and have little use for it, it's easy to completely forget about it.  Tissues became thin and dry, in more extreme cases the walls of the vagina adhere to one another, losing patency. In lay terms, vaginas begin to close up.

This can be very upsetting when love comes along later and we are faced with months of therapy to reopen and restore the vagina. It can be done, but it’s so much easier to maintain patency than to lose it and then work to get it back. Often you can't completely restore what is lost.

What does it take to maintain patency? There are plenty of options ranging from localized estrogen therapy you can discuss with your doctor, or use of vaginal moisturizers, lubricants, and dilators. We also recommend regular clitoral stimulation, to maintain blood flow and keep your clitoris strong and responsive. And of course, Kegel exercises, which will not only help us maintain strong orgasms, but helps us retain urinary continence too.

We work hard after 40 to maintain our skin, our hair, our bodies, brains, and hearts. Why not our vulvovaginal tissues too? Strong vaginas are not just for couples!

Finding a Sexually Literate Doctor

None of us get through our adult lives without some questions about sexual functioning. And we go lots of places for answers, consulting family, friends, texts, the Internet, piecing together a quilt of inter-generational wisdom and ideas, sifting through marketing hype at the drugstore, trying to self-diagnose our situation and find the fastest-best-cheapest way to make it better.  Or sometimes we simply live without answers to our questions, wondering and miserable.

This is a time-consuming and inexact way to learn that can lead to some uncomfortably misguided behaviors (Yogurt douche, anyone?).

Is there a better way? We think there is: You deserve a Sexually Literate Doctor.

Surveys tell us only 14 percent of men and women between ages of 40 and 80 have EVER discussed sexuality or sexual health with their doctors.  I attended a women's sexual health conference this month, and out of 100 people in the audience, only one had EVER been asked by her doctor about sex.

That is, women who have worked for years with their gynecologist to bring their babies into the world don’t discuss sex with them. When discussing menopause symptoms and treatment, sex doesn’t come up. Women are more comfortable ignoring the sexual changes or treating  sexual difficulties from drugstore or pantry shelves than through interaction with their health care providers.

And there’s good reason. For most of our lives, our physicians couldn’t help us. Most of them simply didn’t know how.

Until very recently, not many doctors had the training to discuss female sexual function, and particularly post-menopausal sexual function. As recently as 10 years ago it was common for a physician to receive just an hour or two of training in female sexual function during their entire residency.

That's why I started MiddlesexMD!  Sexual literacy among physicians is getting better every day, but until thorough sexual health training is common in our medical schools, we still have to look around a bit to find a Sexually Literate Doctor who can answer our questions when we need help.

Talking about sex.

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.

Our Secret Recipe for Sex after Menopause

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:

• Knowledge
• Vaginal Comfort
• Pelvic Tone
• Genital Sensation
• Emotional Intimacy

Tada!  Whooot!!! We have balloons falling and confetti rising over here at MsMD headquarters!! How about you?! No?

Wait, 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.)

1. Knowledge

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.

2. Vaginal Comfort

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.

4. Genital Sensation

She needs to compensate for less blood flow and less sensitivity in her genital tissues by providing herself with more stimulation, more sexual sensation.

5. Emotional Intimacy

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.

Adult Trade Show Newbies

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.

A Little Conversation About Mindfulness

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.

Female Anatomy 101

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...

“The shaft?!"

"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...

How I Came to Care about Menopausal Sex

...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:

• Do you have concerns about your sex life?
• Do you have a loss of interest in sexual activities (libido, desire)?
• Do you have a loss of arousal (tingling in the genitals or breasts; vaginal moisture, warmth)?
• Do you have a loss of response (weaker or absent orgasm)?
• Do you have any pain with intercourse (vaginal penetration)? If yes, how long ago did the pain start? Please describe the pain: Pain with penetration? Pain inside? Feels dry?

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:

• Perplexed—because they don’t understand what’s changed.
• Disappointed—because they expected there to be more .
• Frustrated—because they don’t know what to do about it.

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!