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The Fullness of Midlife

"Relationships need cultivation; they need work."

by Dr. Barb DePree MD

Michael Krychman with Dr. Barb

Michael KrychmanDr. Michael Krychman serves as the executive director of the Southern California Center for Sexual Health and Survivorship, medical director of Sexual Medicine at Hoag Hospital, and clinical faculty member at the University of Southern California. A gynecologist, obstetrician, and clinical sexual counselor, Michael is an author of several books (three of which we offer in our shop) that reflect his desire to help patients and their partners overcome sexual health challenges and experience a higher quality of physical intimacy. He has been an advisor to MiddlesexMD since our first year of operation.


Dr. Barb: Today I’m speaking with Dr. Michael Krychman, a long-time friend and advisor to MiddlesexMD. Michael is an obstetrician and gynecologist specializing in sexual health and couples’ intimacy, as well as in survivorship medicine. Michael is also the author of 100 Questions and Answers About Life After Breast Cancer and also co-authored The Sexual Spark. He’s also authored many journal articles in the area of women’s health and women’s sexual health. Welcome, Michael!

Michael: Hi Barb. It’s great to be here. Thank you for having me.

Dr. Barb: Yes, and thank you for taking the time to join me so listeners can hear a little more about your area of work and, more specifically, about women’s sexual health.

I know a lot of your time and energy is focused on couples and couples’ ability to regain intimacy often. So what are some of the most common obstacles you encounter in your practice in helping women navigate this?

Michael: Well you know, Barb, I think because of my clinical practice I have a diversity of patients – different backgrounds, different ethnicities, different age groups – and I think that the commonality between what has been going on in the diversity of couples is really the change in communication and really a function of society. We are becoming very very stressed. We’re working longer hours – harder hours – to maintain the same level of financial support for our families. We’re not eating well. We’re not sleeping well. We’re not exercising. And the things that we should prioritize in terms of communication, in terms of connectedness, are really falling by the wayside. So we’re not taking care of ourselves on a physical and emotional plane, as well as the fact that we kind of put our relationships in autopilot. We feel like they are going to just continue to be positive and move forward, and we don’t put enough effort into it.

I typically see a breakdown in communication. People are not even talking to face-to-face. They are communicating by text, by sticky notes. They don’t spend time together. They are not really communicating on a “couple level” in terms of emotional intimacy. They are really very often business partners or co-managing a household. They talk about operational things – the kids, soccer, tennis, and what have you. But they really need to start refocusing on maintaining that relationship. So very often it’s really a return to the importance of what is actually going on in the relationship. Focusing on the dyad, focusing on the couple themselves, and really trying to re-understand what the importance of those facets are.

Dr. Barb: I’m interested. Do patients present to you with other sexual complaints other than relationship issues, and it’s not as a much of a physical issue as much as it is in turn a relationship issue?

Michael: Well, you know, Barb, I’m both a sexual medicine gynecologist and also a sex therapist. And as you, in your clinical practice, you really do the diversity of both mental and psychological, very often patients will present with one issue, and it’s really a function of a conglomeration of issues. So sometimes women are having physiological issues – they may have menopause and dryness and discomfort – and again that may not necessarily be the primary issue. They may not be interested. So they are avoiding, they are not aroused, and subsequently, their natural arousal mechanism is not being activated or utilized appropriately.

So again, it’s kind of what I would say a sexual medicine detective story that unfolds. You really talk. Sometimes they come in about a physiological issue and ultimately – there’s medical – but ultimately at the end, there’s more stress and fatigue and relationship issues that are the co-primary impact factors. Alternatively, you may have women come in and say there’s low desire, and there’s no interest, and you may find out that the primary issue is an undiagnosed medical issue. So again, I think it’s a balance. But very much so we need to look at both of those facets in tandem and see how they work together.

Dr. Barb: In your book, The Sexual Spark, you provide some really practical assignments for couples. Take me though a little bit of that. What might help couples achieve a more intimate relationship? What kinds of assignments are you suggesting?

Michael: This was a book that I co-authored with a female gynecologist, a great colleague of mine, Dr. Alyssa Dweck. We kind of were – I’m on the west coast and she’s on the east coast – and we were talking and collaborating and really seeing that the same kind of issues are prevalent, irrespective of geography, irrespective of age – some are more common as the duration of relationship increases – but I think one of the big issues is sex gets very boring. A sexual script is like reading the same book. Although you may have your favorite book and really enjoying it, reading it three times a week, the same story, the same beginning, middle, and end, sometimes can be boring and problematic, and it really becomes much more operational than a sensual journey.

Modify the sexual script. Be unpredictable. Be playful.

One of the biggest issues is modify the sexual script. Be unpredictable. Be playful. Focus on sexual pleasure and the journey of sex rather than just the ultimate goal of sexual orgasm. I think that’s a very important issue that we sometimes forget about.

Dr. Barb: It sounds like you’re talking about couples discovering more novelty.

Michael: Yeah, and I think that’s an important facet. Very often we have a sexual script. You know if you ask women how they know their partners are amorous, they often will tell you the same story – he turns off the television, he takes his shower, puts on his lucky shorts, you know, scooches on over to the bed. And it’s a really well-contrived, controlled script that unfolds like a favorite book, and it’s very predictable. Many couples gravitate toward that because it is safe. It’s comfortable. It’s like wearing a comfortable pair of shoes. You know your feet are going to be comfortable at the end of the day. But sometimes it’s important to spice it up – sexual accessories, sexual positioning – you don’t have to go to Fifty Shades of Gray novelty, unless you’re interested and it’s not for everybody – but sometimes just modifying the script changes your biological-neural-hormonal environment in which you act. It increases oxytocin, it increases noradrenaline, which will certainly help the overall experience.

Dr. Barb: You’ve even brought this to couples’ retreats where you’ve gone to some really cool locations, and couples have joined you to really do some hands-on instruction around that. I’m just curious, can you outline what one of those retreats might look like?

Michael: Yeah. That was really exciting. I was doing some retreats all over the country; even in exotic locations like Bora Bora, where you really give people, you know, you do a variety of exercises, and we talk about trust exercises. We talk about anything from creating a sensual environment, or talk about feng shui sexuality, how the environment in which we live – our bedroom, our home – how is that influencing our sensuality and sexuality? We talk and do trust exercises. We had couples go swimming with the sharks, and how different positions and different levels of excitement and concern can rebuild sometimes trust that may have been weakened over time. We rehash and revive and restore the problems that may have experienced in the early part of the relationship to learn from those. You know, those that do not learn from the past are doomed to repeat it. So really, talking through exercises. And, using a very sensual environment that focuses on the couple really enhances the overall experience. So we are trying to use all of the senses. We have a beautiful environment in which the event takes place. They have periods to do private behavioral exercises and take back to the privacy of their own rooms some of the things that they have learned in order to enhance their overall marriage and sexual experience.

Dr. Barb: Are those available to couples who would like to reignite their own relationship? Are there organizations who provide those kinds of weekend retreats that someone could investigate and consider attending?

Michael: Yeah, there certainly are. This was organized by a specific organization. I’ve done ones where couples have gotten together amongst their friends and organized it. It doesn’t have to be in an exotic location like Bali or Bora Bora, what have you. We’ve done them in major cities. I do them for small groups, I’ve done them as well. So again, there’s a variety of organizations. I think you just need to look at the details of the program, what you are looking for, and what you want to get out of it. Again, there are variable in time, variable in professionals that do them, but again certainly are very available at a variety of times throughout the year.

Dr. Barb: You also have an interest and focus of your practice on survivorship medicine. Can you talk a little bit about your observations of, specifically, cancer survivors and how they are affected sexually and what you might do to help promote sexual health for that group of women?

We are all surviving somethingMichael: You know, I think you bring up a good point. Cancer survivorship I do, I certainly have a whole variety of patients in my office. I worked at some Kettering [Memorial Sloan-Kettering Cancer Center, New York] for quite some time and I do have a large group of patients who do have cancer. They have the added issue of being poked and prodded. They have both physiological issues from the cancer and other facets in terms of keeping the cancer from occurring, whether it’s chemotherapy and radiation. So they certainly have a lot of physiological issues, coupled with the concern of recurrence, of pain, fatigue, as well as the financial and child-bearing concerns that all of us do face on a regular basis. So again, very special attention to reconnecting. Sometimes cancer is viewed upon as a third party which is invading the relationship. So again, the same kind of path. Survivorship for me in my definition – originally I think, when I first started practice about two decades ago, primarily focused on cancer. But really if you think about it, Barb, on a global level, we are all surviving something. We all will grow older, will have a chronic disease, the average women will take about four medicines chronically as she enters the menopause – survivorship is really about wellness and about prevention. How do we stay well? How do we prevent disease? Irrespective of your diagnosis, I think we are all surviving something. How do we optimize that?

It’s back to the grass roots of precision medicine – diet, exercise, stress, of course sex is very very important from a biological and an emotional standpoint. We know sexual health and general health are very much intertwined, that’s probably the take-home message that sex is a very important physiological activity, and we need to address it and optimize it given the patients and what their specific needs are,

Dr. Barb: It’s interesting you say that because yesterday I was at lecture given by a pain management specialist. I’m also preparing a lecture for community, and it just feels like the common message that we are coming back to with women specifically, and men as well, is really lifestyle. It seems so basic, but I think physicians over the last 20 or 30 years have gotten away from some of that and are more quick to prescribe things and, like you said, we are symptom of our culture right now where we are much more fragmented in relationships and time and intention that our message has to be about the basics of lifestyle. It’s always just remarkable to me how impactful that is. But I don’t know that individuals are willing to invest in that. Has it been your experience that when you emphasize it, you find people actually are engaging to make changes that will favorably impact their relationship?

Michael: Well, I think in the acute crisis, people are very eager to make change, but preemptively people fail to recognize. We kind of ignore the important things that are going on. So I think it’s really important to recognize that specifically that we very often fail to recognize the most important things that are going on until it’s too late. Sometimes it’s too late and the damage has been done.

Relationships need cultivation; they need workRelationships are challenging, they need cultivation, they need work, but I also think that in today's’ day and age, we are a victim of our society. We don’t take care of ourselves. I just submitted an op-ed to the New York Times about sleep, and chronic sleep deprivation, and how people devalue sleep. If you sleep a lot, you are lazy, right? You are not productive. But sleep is a critical facet to the human psyche, biologically and physiologically. So I do think that we need to go back to the basics. Very often what we are now moving towards, Barb, is what’s called precision medicine: optimizing the medical experience on an individualized level. No two people are going to experience the same disease in the same way. No two people experience sexuality in the same way as well. So we need to kind of understand those issues and the impact and how that will help us towards optimizing health as well.

Dr. Barb: Is there a resource you could give for those who want to find professional therapy with a sexual focus in mind?

Michael: What I would recommend, you know, I think that there are a lot of very good resources. I think we can refer people. There’s the American Association of Sex Educators, Counselors, and Therapists. I think that’s an excellent resource. The International Society for the Study of Women’s Sexual Health. I know your blog has been exceptionally helpful in connecting women with other women. I think there is certainly a growing network of increased awareness, both amongst patients, both amongst providers. And again, many clinicians like myself and you do engage with patients over telemedicine. I think it’s really important to recognize that patients are not alone, and that there are certainly a lot of things we can do to help them help themselves. I think you can seek and you shall find, right?

Dr. Barb: Yes, good. And you’re always on the cutting edge of what’s next and what’s coming. Is there anything we can look forward to in the upcoming developments for treatments or understanding around women’s sexual health?

Michael: The biggest exciting thing was the latest approval just recently from TherapeuticsMD in Bexy which is a bioidentical-vaginal insert that you can put directly into the vaginal mucosa for moderate to severe dyspareunia – a symptom of VVA due to menopause. We have had what they are calling the “Real Launch of Addyi.” As you know, it just happened. It’s going to be available by telemedicine at So this is getting more press, more notoriety, a lot of articles coming out on Flibanserin or Addyi really at a cost effective way to get it to women who are really needing it.

In addition, Bremelanotide, which is Rekynda, is a [subcutaneous] on-demand injection for changes in female sexual dysfunction, and has been filed at the FDA. So I would stay tuned. That’s probably coming down the pike. We don’t know exactly when, but it should be going to the FDA for approval and discussion. I know that the file has been submitted, so I think we just need to kind of wait and see where that goes.

Dr. Barb: Good! Well thanks. It’s an exciting time to be involved in women’s health, and I think we are going to have continued additional options to offer our patients.

So in closing, Michael, can you share with listeners where do you find richness as this stage of your very very busy life?

"No" is a complete sentenceMichael: I think for me the biggest richness and the biggest thing we need to focus on as health care professionals – I mean what I think is really interesting to me is that we are now seeing an increased incidence of suicide, increased incidence of problematic of professionals – overworking, underpaid, very stressed out, electronic medical record, a lot of impact in terms of how they function. I think the most important thing that recharges me is trying to develop a balance. As you and I are passionate about what we do, we practice happy medicine, we give back something that has been missed and belonging to patients. I think at some point we need to have a balance. And many people are out of balance. And that is really personal and professional goals, setting limits, and I would say “no” is a complete sentence. Sometimes we have to learn that balance and take care of ourselves in order to better take care of our patients.

Dr. Barb: Good. Well thanks so much for sharing with us today, Michael. I know listeners appreciate your insights. Thanks again for your time.

Michael: Thank you, Barb. It’s always a pleasure to be here, and thank you for all that you do.


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