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“Just Say Yes”
By Michael Goodman, M.D.

Few things in life are fun and free. Sex is one. As Henry Miller said, “Sex is one of the nine reasons for reincarnation...the other eight are unimportant”. Just as lack of sex begets even less sex, reinstitution of sexual relations begets more sex. Like with potato chips: “ you can’t eat just one...” (no pun intended).


It is hard to fight nature, but in the case of sexual and sensual enjoyment, it is a fight worth engaging. Our genetic engineering, oriented towards preservation of the species, doesn't’t mind if our sexuality withers after fecundity declines. But if we don’t use it, we lose it. Several things conspire against us:

1. Women’s Issues: It is hard to feel sexy if you are flash-flushing all the time, moodiness is your middle name and the last time you had a restful night’s sleep was sometime last July! Then, if you get past all that, what’s about this dryness thing? Sex is not supposed to hurt. It is supposed to be pleasurable. Isn't it??

It is hard to feel sexy when your teenage daughter tells you how much cellulite you have and how much weight you gained; when size eight is a distant memory and when your aged mother calls (the third time today) to say your dad has slipped and fallen in the bathtub.

You used to love sex (or at least like it a fair bit). Now you could care less if you ever get any again or not. Maybe once you get started (if your arm is twisted) you do get aroused (sort of...)--and orgasms are still quite satisfying (even if it does take longer), but sex is nowhere on the “priority list”. (Didn't always used to be like that...). You feel sorry for your husband. Poor guy--he hardly asks anymore, he has been turned down so much. What is worse for him is to be accepted--but feel like he is being accommodated. It was some time last month when you last had sex!

2. Men’s issues are divided into the “want it but know she-ins't-gung-ho-so-what-do-I-do?” situation, the “well I'm not really interested either” bag, and/or some variation on the “can’t get it up/can’t keep it up” theme.
Just as hormonal issues--the sudden variations and loss of estrogen production and the slow steady decline of testosterone-- impact a woman’s sexuality, testosterone loss frequently impacts men with loss energy and libido as well.

3. Medication and Health Issues: Some of the medications we (both men and women) take as we transition through midlife tends to have significant effects on both sexual interest and ability to orgasm.
Mood and depression difficulties (which in itself can diminish desire) sometimes result in administration of anti-depressant medication. This may be a double-edged sword. At the same time as anti-depressants, such as Prozac, Paxil, Zoloft, Celexa, Lexapro and Effexor, make life smoother and easier to live, they may, to a greater or lesser degree, diminish sexual desire and responsiveness in both women and men.

Other medications, most notably certain antihypertensives (blood pressure lowering medications), may have similar effects, especially in men.

4. Discomfort Issues: As if all of the above weren't enough, one of the greatest banes of midlife sexuality for women is the loss of vaginal lubrication, dryness and discomfort with the stimulation of lovemaking.
The vagina is exquisitely sensitive to estrogen. Remember how “juicy” you were when you were pregnant with estrogen levels skyrocketing? Likewise, one of the earliest heralds of the falling estrogen levels of midlife is vaginal dryness and sensitivity. Remember when (aahhh!) you used to get “wet” when you had a sexual thought (oh, c'mon now—it wasn't that long ago!). That clear, sticky liquid just outside the vagina was secreted by your Bartholin’s glands, providing outside lubrication for enjoyable intercourse.

Unfortunately, these glands regress with the diminishing estrogen levels of midlife, and their secretions are minimal. Tissue thinning, less secretions inside and out: not a very sexually inviting situation, and one that leads to irritation and tearing of the sensitive tissues just outside of the vagina.

5. Men and women are different: (So, what else is new?) Actually, this is important if you are to progress past midlife sexual ennui.

The Masters and Johnson model of sexuality (desire leading to arousal leading to intimacy, plateau and orgasm) is a male model. Women are different, as described in the more accurate Basson model of female sexuality. In Dr. Rosemary Basson’s model, intimacy comes first (the opposite of the male model). An understanding of these principles is important if sexual intimacy is to be reestablished.

Men and women are different. Desire is the initiating factor for men (no desire/no erection); it is not necessarily so for women. Nothing wrong with that. As you will see, delightful sexual intimacy can evolve outside of the genesis of “desire”. Unless low testosterone is a factor, most midlife men walk around in a more or less continual state of desire. If something occurs—such as an erotic image, the curve of a breast, imprint of nipple, flash of eye or thigh—that man gets aroused, and he desires...intimacy!

It is just the opposite with women. Most women don’t get turned on if their husband walks around in his skivvies. Women's sexuality is "circular." A woman's sexual response begins with availability; in order to be "available," there must first be trust and intimacy. Then, if there is some physical intimacy (touching 'n cuddling...)there just may be arousal... and desire for sex. Men are linear: desire?arousal? sexual intimacy. Women, circular: availability/intimacy?arousal?desire. (And, if sex is satisfying, this leads 'round again to availability.)
These things are normal. They are the “way of life”. But they certainly effect sexuality, sexual desire and satisfaction. To change requires conscious effort. All of this doesn't seem to come naturally, but the prize can be sweet.

Vaginal dryness and discomfort: Easy. Just as the vagina is sensitive to lowered estrogen levels, it recovers just as quickly. “A little dab’ll do ya...”. Replens is an easily available over-the-counter vaginal moisturizer. If this is inadequate, a small amount of estradiol or estriol cream, estradiol tablets, or a small in-place estradiol-releasing vaginal ring can all, in short order, rejuvenate the vaginal mucosa (lining), with minimal systemic absorption (if you want increased absorption, increase the dose).

There is a second and separate issue, however. Penises don’t shrink to accommodate the thinning, mild atrophy and dryness of approaching menopause (welll...sometimes they do...), and a woman’s introitus and perineum frequently become traumatized. Since your Bartholins aren't doing their thing to make you slippery, you may now have to supply your own lubrication, but there is nothing wrong with that, and it can even be fun!

There are lots of sexual lubricants on the market, and they come in names like “Silky”, “Astroglide”, “personal lubricant”. All of these products are water-based and use glycerol and propylene glycol for their active ingredients, which means that they are cool and eventually become tacky and dry out. They are usually used on an as-needed basis to, well, help things “slide in”. Not terribly sensuous.

My suggestion is to use either a mousse (like "Intimate Options"), a silicone-based lubricant, or a light oil. Unless you are using a condom, or plagued by recurrent vaginal infections, I recommend a light oil--massage oil, light olive oil, mineral oil is great. Have a little bottle at the bedside (or wherever...). Each of you can put a little on your palms, rub them together to warm the oil, and...Play! I am sure neither of you would mind much if the other sensuously applies some oil to all of those parts you like stroked. You can talk and fantasize as well. This leaves a thin coat of oil (which will not dry up) on the various parts that will benefit from lubrication and it becomes much more than just applying lubrication at the last minute so that...”it goes in easier”.

Other great ideas: Besides the vaginal rebellion that occurs in women when their estrogen goes south, the combination of insomnia, mood swings, hot flashes and other disturbances resulting from low estrogen levels couples with the direct effect of diminished estrogens to impact women’s sexuality. Testosterone levels frequently have been going down also (one-half of a woman’s testosterone is secreted from her ovaries—the other half converted from the adrenal glands). This combination can be a 1-2 punch which can be a particularly heavy knock out for those women who experience surgical or chemotherapeutic menopause. Estrogen supplementation can be a lifesaver here.

Have your testosterone checked also and supplemented if your bioavailable testosterone is low. A serum (blood) testosterone alone is worthless here. Only 1% at best of the testosterone circulating in a man or woman is utilizable by the body—the rest is bound to the blood proteins sex hormone binding globulin (SHBG) and, to a much lesser extent, albumin. A woman (or man) can have a low-normal or normal testosterone, but a normal or upper normal SHBG and a healthy albumin and have very little bioavailable testosterone. Salivary testing may also be of benefit here, since in order to get into the saliva, the testosterone must be available to the salivary gland to be incorporated into its secretions. Signs of possible diminished testosterone in women are low sexual desire, more difficult arousal, loss of energy and a general decreased joie d’vivre.

Men can be in the same boat here. Although a man’s testosterone levels are maintained longer than a woman’s, the same thing (lowered testosterone coupled with not lowered SHBG and albumin) lead to only a fraction of 1% of his total testosterone being available, leading to decreased sexual desire, “oomph” and energy and also leading to poor response to erectile agents (if testosterone is low).

Again, a simple blood testosterone is worthless. Testing must include total testosterone, SHBG, albumen (+/-) and free or bioavailable testosterone. Salivary testosterone as well is nice, to see if it is concordant with blood values and is also good to easily follow results of therapy.

Most readers still with me to this point know the uses of erectile agents (Viagra, etc.) in men. What you may not know is occasionally they find usage in women as well—specifically in women with peri/postmenopausal arousal or orgasmic difficulties, who had no such difficulties when they were younger. These agents do nothing for “desire”, however, in women.

But, you know, you can have great sex without desire. Don't beat yourself up if you feel your desire waning. Read on, read on!

“DATES”: Remember when you used to go out on dates? How maybe you would look forward to a little nookie at the end of the evening? Well...resurrect that concept! Here is a great way to resuscitate your barely existent sex life, and put matters “on your turf”.

If you are like so many of my patients, your answer to the question of when you last had sex is an embarrassed “...sometime last month...” Remember: “Use it or lose it.” Remember that (once dryness and lubrication is corrected) it is sorta nice...once you get into it. Remember the bind your husband or lover is in. “...To ask or not to ask...” Remember the discrepancy in the “...Desire/intimacy equation.”

You can put matters on your turf! Schedule Intimacy First. Take the pressure off and have fun. Here is how:
At least once per week (if you are having sex every month or so) or twice a week (if your present frequency is about once every week or so) SCHEDULE (--on the calendar—inviolable--) time for physical intimacy. At least an hour. Daytime or early evening (not squeezed in late at night). A time when the kids will be out of the house (or you can arrange to have them out—with a “wink” if needed) in bed (or the comfortable place of your choice). Scanty clothing and/or “special garb”. Oil, music, “toys”, erotica, etc., all at the ready.

Anticipation...preparation...intimacy...promise,(and remember, foreplay can begin at the beginning of the day, taking extra care nice to each other).

The pressure is off both you and your partner. He does not have to worry about being rejected. You don’t have to worry about lack of desire as, in this scenario, desire is not the initiating factor. It is on your turf. It puts intimacy first and of course does not preclude other (non-scheduled) interludes.

Also--it is never too late for “new tricks” and explorations. There are many websites specializing in sex toys and erotica. Go to the erotica section of your local bookstore and browse. Anything written or edited by Lonnie Barbach, PhD, is good. (Re-)explore “The Joy of Sex” and “More Joy”, both written by Alex Comfort. Many books, including “Getting the Sex You Want: A Woman’s Guide to Becoming Proud, Passionate, and Pleased In Bed” by Sandra Leiblum, PhD, “How to Have Magnificent Sex: The Seven Dimensions of a Vital Sexual Connection”, by Dr. Lanna Holstein, “I Am Not In the Mood: What Every Woman Should Know About Improving Her Libido”, by Dr. Judy Reichman and many others are wonderful starters.

...Again: Don’t get hung up on desire. If you choose hormone therapy, especially if supplemented with testosterone, this aspect of your sexuality will improve, but not necessarily dramatically. Remember, desire and frequency of sex is not as strictly dependent upon age, but on length of relationship. An “old married couple” of 29-year-olds who have been together 10-11 years will have sex less often than a couple of 55-60 who are new lovers. It is okay not to have rampant desire. So what if it takes longer (“the further from the branch, the sweeter the fruit...”) It takes him longer too...and gives the Viagra time to work!

Michael P. Goodman, M.D. practices gynecology, perimenopausal medicine, bone densiometry and sexual medicine at “Caring for Women” in Davis California. His newest books are “The Midlife Bible—A Woman’s Survival Guide”, and"MEN-opause: The Book for MEN", released in 2007. MPG:lh



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