Over-the-Counter Aphrodisiacs with Possibility

Many of the women I see in my office want a “natural” treatment for their sex life. They don’t want a prescribed medication if they can get their libido back in some other way. Many experiment with trying over-the-counter herbs fully aware that there may be more hype about love potions than actual fact, and hopeful that there is some truth to the marketing.

In this blog post I point to the medical research that has been done on the over-the-counter products that are out there now; these products are available to everyone, and yet they are not safe for everyone to use. The comments below outline for you what is known about these products from medical research.

The info comes from a 2015 review presented in Journal of Sexual Medicine. The review was done to answer the same question: Was there was any evidence to support all the claims of sexual wonder?  It turns out that fenugreek, Korean red ginseng, maca, L-arginine and tribulus terrestris are plant products that did show supporting evidence, even if the evidence was limited in scope. I have included a few details from this review of research below.

Fenugreek: Fenugreek is an herb, often used in Ayurvedic medicine, which contains building blocks used to create estrogen and testosterone. A 2015 study showed that fenugreek improved arousal, lubrication, and satisfaction in premenopausal women. There were minor intestinal side effects. The dose used in the study was 300 mg twice a day. Fenugreek should not be used by people taking blood-thinning medication (anticoagulants), or by women with hormonally active cancers.

Maca: Maca is a root vegetable from Peru and has long been used for fertility in the Andean culture. Three out of four of the random clinical trials mentioned in this review did show positive effects on sexuality. Study doses ranged from 1.5 to 3 grams of maca a day. Its mechanism of action is not fully understood. It is known to not alter estrogen and testosterone levels as fenugreek does. It does contain phytoestrogens, plant-based compounds that can inhabit the estrogen receptors in your body. This can be a good thing or a bad thing depending on who you are, your hormonal status, whether you have cancer, the medications you are on, and many other factors that researchers are currently trying to decipher. Maca is well tolerated. We do not yet have data on what doses are optimal or safe for women to take.

Ginseng: Korean red ginseng is an herb that has been shown in one double-blind study to heighten arousal in menopausal women. It works by encouraging the release of nitric oxide, which improves blood flow in the clitoris and vaginal walls. (This is the same biochemical pathway that is augmented by Viagra, Cialis and similar medications.) Ginseng has been shown to be estrogenic, so it should be avoided by women with hormonally active cancers, and by women who have bleeding disorders or are on anticoagulant medications.

Tribulus Terrestris: This herb contains a compound which converts to DHEA. DHEA is a building block for your testosterone. This review found two randomized placebo-controlled studies that demonstrated improvement in female sexual function using this herb. The herb was well tolerated and sometimes caused minor intestinal side effects.

Horny Goat Weed (Traditional Chinese Medicine herb), Potency Wood (Brazilian herb), Damiana Leaf (extract from a Mexican shrub), and Gingko (tree used in Traditional Chinese Medicine) have promise, yet lack research. Yohimbine (parts from an African plant) is a strong aphrodisiac and its side effects can be life threatening, so it is not recommended for any over-the-counter use.

L-arginine, a common amino acid, is taken by many men and some women for a Viagra-like effect. It is a precursor to nitric oxide and nitric oxide causes blood vessels to dilate and fill with blood all over your body, including the clitoral and vaginal areas. There is significant evidence that L-arginine is helpful in producing firmer erections in men. Research on L-arginine by itself in women is lacking. There is a small double-blind study of 108 women that showed an increase in sexual desire and sexual satisfaction after taking the supplement ArginMax. This is a multi-ingredient supplement which has L-arginine in it, along with a variety of vitamins and herbs, some of which we have just mentioned: Korean Ginseng, Ginkgo, and Damiana Leaf.

Medicine, to date, hasn’t generated enough evidence-based data to establish guidelines for safe use of herbs over time, so we are left somewhat on our own. I say somewhat as there are naturopaths, herbalists, and nutritionists who are well educated in the potential of these plant products and have used them clinically for decades. Be careful in experimenting! Herbs are powerful products, and as you can see above, they can increase hormones in your body that can contribute to cancers and blood clots.

Adding your feminine energy into your relationship chemistry raises the excitement level for both of you. It increases desire and appreciation in both the male and the female, and works in non-binary relationships. Even in relationships that have suffered decades-long dry spells, things can turn around quickly, even immediately when this is engaged. It takes only one person in the couple to get things going. If you, as a woman, claim your feminine sexuality and express it, you can get your partner’s attention. When you get his or her attention you can use it to enhance your dynamic and to bring you closer.

Patty and Paul Richards introduced me to this dynamic years ago in their work and subsequent book, Wild Attraction, a Ruthlessly Practical Guide to Extraordinary Relationship. In this model of relationship women want men who will give them personal, sophisticated and positive attention, and men want women who will provide them sexuality and charge.

I have been warned that this dynamic sounds too traditional and stereotypical and is not a contemporary value.  I would argue that it works, and most women I work with want to feel closer to their mate and want a romantic aspect to life that can be found here. Going here is going in the opposite direction of a ships passing in the night relationship. This is not boring. You make something happen because you express being an alive sexual feminine being.

When you engage this dynamic you heat things up. By this I mean it works to increase your intimacy and how available you are to each other.  Over time, your trust in each other creates an internal relaxation. Newly found aspects of yourself arise. These aspects may be more experimental or they are deeper or feel more raw or animalistic than you used to experience.

If your relationship is not exciting to you now, take a look at this dynamic and see if it is playing out in your relationship now. When a man (or the partner choosing to express more ‘maleness’) frees up his/her attention and places it in a positive and attentive way on his/her wife or partner, and when a woman confidently claims and expresses her sexuality, things in the bedroom heat up.

The nice thing that I have observed is this: though it takes two to tango, it only takes one person to start things rolling in that direction. You can be that one. Own your femininity confidently and make it more real and visible to yourself and to your partner. It is not just your body you are sharing, it is your aesthetic, your motion, your being.

One way to do this is to highlight your body. When you accent your curves, or emphasize your femaleness, you create a good kind of tension that can ignite desire in both of you. Or you can hide your curves, your breasts, and hips, and keep the tension down. You can wear a sheer, lacy nightgown that shows your silhouette, or you can wear flannel pajamas. A choice that accentuates your femininity both to yourself  and to  your partner is more likely to ignite passion.

Yes, you are tap dancing on your partner’s attention by playing up your feminine shape. You are doing it to increase the passion and excitement that you both experience. You may have been discouraged to accent your female form in the past, fearing being seen as ‘loose’, or as a manipulator.  But inside a safe and respectful relationship where power is played with to enhance intimacy — not to oppress a person — you can use your femininity as a powerful additive. You can use your voice seductively too. This is quite different than accenting your breasts and hips when walking past a construction site with working men whom you don’t know, and to whom you are not promising any future intimacy.

As simple as this sounds, dialing up the feminine is not an intuitive action for women. Trisha was 62 when she intentionally added her feminine sexuality into the mix, and her boring sex life turned around that same week.

Trisha came to an evening class because a friend had told her it had helped her get her sex life  going again. Right after the first class finished Trisha came up to me and asked if she could have a different homework assignment.  She said “You need to understand, I don’t have any libido. I can’t do these things. I don’t have any desire for sex.”  “Do them anyway,” I said. I wasn’t being unkind. I knew that the best way for her to find her libido was to take action.

The following week Trisha was the first to raise her hand. She reported that she had done the assignment even though she didn’t expect any result.  She was shocked. She had dressed up in a sexy way, put on lipstick and eye makeup, and gone on a date with her husband. She flirted and they had fun. She already felt juicy again.

“I was so surprised. I didn’t believe I could. I did all those things thinking nothing would happen. Now I am looking forward to sex with my husband!” Three months later, I followed up with her. She referred to her sex life as “hot.”

“I did not know that I could control feeling horny through my mind, through thinking about sex, and through dressing up like I used to when I was sixteen or twenty-six and feeling beautiful. I think the key for me is really attention. Like you said, I can create that same feeling of hormonal need now, after menopause, by giving my attention to sex and feeling sexy. Part of all that is getting dressed up a little bit and going out somewhere in the evening, which we know isn’t the sexual part but we do it anyway. I like getting dressed up, knowing full well what’s coming later, and flirting, and making an event of the whole process so that I am feeling quite juicy by the time we even hit the bedroom. All of those things have rekindled my desire. I actually feel horny again!  Sounds kind of trivial and superficial to remember to dress sexy again. Luckily we have great bodies, so why not use them and dress sexily and not worry about the fact that I’m sixty-two years old. No, I should not! It’s the whole process—the way I dress and look, to the way the bedroom is decorated, to creating events, to having dates. Maybe going out for a six course meal, maybe going out for a martini, or something, but somewhere a little elegant.”

Overall, Trisha said her sex life has gone from boring to hot; in fact, her word now is “uninhibited.” She gives herself over to the experience of sex. Her mind quits and she allows her body to take over. There is no control, and she can get lost in the experience. It feels like freedom and openness to her. It feels like coming home.  She gets that luscious experience of oneness, the feeling that there is no separation between her and her husband. This lovely anticipation and the following deep satisfaction had been missing from their sex life for a decade, ever since menopause.

Connecting sexually, Trisha said, has brought in more tenderness and respect. “We are both far more loving in the little ways throughout the day. It is just sweet. It really has improved in small ways which is lovely. There’s a wonderful sense of gratitude for each other. Our little secret of what we’ve done here together in the bedroom spills over to appreciation in all the other ways as well.”

Trisha found that if she and her husband got into “work mode” for days at a time, they would schedule a date, and the good sexual tension returned. If Trisha missed sex first, she asked her husband to create a date. She liked it when he asked her to go on a date. His expression of desire for her added more romance, and she found romance arousing.

There is another half to this dance and that is how the male can start things up with you — how he can get things going, or keep things going, even when you are not feeling engaged romantically or sexually. He can do this by paying attention to you, giving you positive (not demanding) attention.  Is your partner paying attention to you in a way that is personal and nourishing? Do you feel included in his/her attention most of the time even when you don’t need anything? Do you feel connected to him even when nothing is going on? If the answer is no, you — like Trisha — can be the one to start that dance going. Even though she thought nothing would happen, she did the assignment and got surprised.  Start your tap dance. Tap dance with your partner’s attention by adding your feminine energy into the moment. Accent your curves, flirt, wink, wiggle those hips, play with his attention. Remind your partner you are an alive feminine sensual being who wants to connect. Don’t let him forget.

 

Click here to read my blog post about the female body and sexual pleasure.

Set the Stage for Delicious Sexual Events

Are you an alive sensual feminine being who has a yes for pleasure, and wants to have a great bedroom experience with your partner?  Then design your bedroom to be a great space for a romantic and sexual encounter. No kidding – intending your bedroom space to be sensually great for you makes a difference to your sex life. This is even more true in long term relationships.

Make the bedroom a place that turns you on – a room that reminds you to feel your sensuality as soon as you walk into it. Declare this room to be only about the sensual wonder and magic that is possible between your partner and you. Even if you’re not feeling that magic in the relationship yet, make the room feel and appear as if you are.

Create the Environment That Invites the Sexual You to Show Up

Imagine a room decorated to match the sex life that you want to have. You can create this by the use of textures, colors, lighting, and accessories. Start by selecting a theme that makes you feel tender, open, and excited. If exotic places create interest for you, include elements of exotic décor. If a romantic style is what revs you up, create that. If clean lines and simple surroundings make you feel most open for love, then keep the room décor
understated.

A quick Google search of exotic, romantic, or contemporary bedrooms will yield endless decorating ideas that you can use to ignite your style of romance. I am not an interior decorator, so I either use pictures of what others have created or ask my décor savvy friends to come over and help me. You may want to ask your friends too. After you explore and recognize which theme works for you, put your plan into action.

The décor should draw your eye to the bed and should elicit the idea of sex or sleep. Nothing else. The bedroom is not a home office, a laundry-sorting station, or a TV room.

Even if the kids still sleep in your room at times, your kids’ stuff, including family pictures, should be placed elsewhere. This is an adult space. It’s your play area. The bedroom needs to reflect an intimate, safe place where you can temporarily step out of the “mom” mindset. The other rooms in the house can be family rooms.

Get rid of everything that is not linked with either intimacy or rest. Be ruthless!

Textures: Use fabrics that invite you to want to touch them. Create a “want to stay a while” atmosphere by adding layers of silk, faux furs, mohair, cashmere, fine linens, and other soft, velvety cottons. Make it a sensual playground.

Colors: The colors of the sheets, bedspreads, walls, and pillows should compliment your eyes, hair, and skin. You are the beauty in the room. Showcase yourself at your sensuous best!

If you don’t know what your best colors are, you can hire a color expert who can advise you or go to the bookstore and find a reference. 1

Lighting: Most women agree that bright light will dampen a sultry mood faster than things disappear when you hit delete on the keyboard. Replace harsh white light bulbs with soft pink ones. If you can, add a dimmer switch. Use candles too. The flickering of candlelight can add to the feel of romance in the room and provide a gorgeous forgiving glow to your skin. If you’re worried about burning down the house, there are many electronic candles on the market that can mimic the same effect. If you want to really shake things up, occasionally introduce strobe lights and/or black lights to the mix.

Accessorize: Add framed, romantic, or sensual pictures of the two of you together to remind you of what this room is about. Add accents of curved vases, sculptures, or other shapes that suggests a sensuous body.

If you like music, collect songs or albums on your iPod or CD player that make you feel sexy. If you have yet to compile a collection of songs that get you in the mood, start listening to music with this question in mind, “What songs make me feel sensually alive and excited?” Create a way in which you can quickly access and play those songs when the mood strikes.

Couples that take the time to set the mood through lighting a candle and playing music have been shown to be the couples that have more passion and satisfaction in their sexual relationships over time.

Make sure to delight all of your senses. Sensual smells can be provocative, and using scented candles or essential oil diffusers can add to your relaxation and arousal. Essential oils that are used to increase arousal include jasmine, cinnamon, ginger, rose, vanilla, patchouli, and ylang-ylang. You probably won’t like all of them, so try several to see which ones turn you on.

If you use oils, lubricants, contraceptives, or other devices, find an easy-access and aesthetic way to store them. Also, include benches, stools, and cushions in the furnishings. They can facilitate different activities and positions. You also may place mirrors in strategic places for visual stimulation.You don’t have to spend a lot of money. You can find many of these items at popular discount stores.

You’ll know your room is ready when you can answer these three questions with an
emphatic “Yes!”

  • Is your bedroom a place that looks like it is ready for a romantic and sexual
    encounter?
  • Does it inspire you to feel sensually activated?
  • Does the décor accent your beauty, your skin tone, eye color, and hair color?

Claiming your bedroom as a special place to enjoy your sex life is a concrete way to declare that your sex life has your attention, and that it is important. Committing to this one change, creating an inviting sensual bedroom space creates a ripple effect that can be bigger than expected.

If your lovemaking space delights your senses, you are much more likely to show up in it with all your senses ready to be delighted. Remember, surrounding yourself with what’s arousing and interesting to you is central to having a great sex life.

Reference: Carla Mason Mathis and Helen Villa Connor, The Triumph of Individual Style: A Guide to Dressing Your Body, Your Beauty, Your Self (New York: Fairchild Publications, 2002), 112-153.

Click here to read more about Women and Sexual Desire.

For more bedroom inspiration and design ideas, visit my Pinterest page by clicking here.

 

A Body Designed for Sexual Pleasure and Female Orgasm

There is quite a lot to celebrate about the female body and how it responds to and is geared for pleasure and female orgasm. It is quite marvelous. When arousal is triggered, cascades of events occur. Neurotransmitters release from a woman’s brain and she gets a nice tingly feeling in her genital tissue. Her nipples become firm, and the clitoris gets erect. Her vulva swells and the labia change from flesh or pink color to a dusky rose or purple. She feels sexually excited. The vaginal walls get suddenly wet. Her clitoris and the surrounding vascular tissue engorges with blood. Some muscles contract and her heart rate increases. Breathing is fast. There is a sense of tension.

On the outside of the vulva, women and their partners can see the glans of the clitoris, that external bump of tissue. This glans has the most nerve endings of any place on her body. This is similar to the head of a man’s penis which is thought to be the most sensitive part of the penis with the highest concentration of nerve endings. Both these glans are very sensitive to touch and they can be extremely so. Yet they are not the whole story of arousal and orgasm. Obvious on the male, yet hidden on the female are the shaft and the two internal legs. The legs of the clitoris are 5 to 7 centimeters in length. The shaft and the legs are what cause both the penis and the clitoris to swell when arousal happens. They become erect. Internal swelling in a female can be felt through the upper vaginal wall in the area we know as the G spot. When swelling is significant enough with stimulation there — orgasms occur.

There is also an area of the vaginal wall that is deeper inside, referred to as the A spot or the Deep spot. This spot, on the upper vaginal wall in front of the cervix, can feel wonderfully arousing. This deep spot is mediated by a different nerve and women report that it feels different than both an external clitoral or G-spot orgasm. Women report they like it being touched directly, with thrusting motion, and they also like it when touch moves across the surface of that area, like skimming the surface of a lake.

The only function of the clitoris and its 8,000 nerve endings is for a woman to experience pleasure, sexual pleasure. The clitoris does not secrete substances or hormones, it does not contribute directly to reproduction or urination, it does not support other processes in her body. It exists for your pleasure.

On top of this awesome genitalia there are the many other erogenous zones in your female body. Your lips, your breasts, your nipples and the skin at the nape of your neck or inner thigh are territories of sensual delight to be explored. Skin can be wonderfully erotic and is packed with nerve endings. Light feathery touch can be scintillating, exploration can be done with your lips, tongue, fingers. There are 2,500 nerve endings per square centimeter in your fingertips, for example, and a lot can be communicated with touch, especially touch that is intended to excite and arouse.

Look at the marvelous features of your  female body, and you can appreciate that the physical groundwork for exquisite pleasure has been pre­-established. Having this sensitive equipment does not mean women get easily aroused. Many don’t. One has to have arousal triggered for this cascade of events to  occur. What triggers arousal and leads to female orgasm is the million dollar question.  Arousal can start long before you get in the bedroom, or it can start in the bedroom. It can start with a look, a touch, a smell. If a woman’s arousal is heightened and sustained on enough of her multiple channels, she will have a great experience.  The equipment for her pleasure is there, and one needs to know how to use it to.

PS: What works to get you aroused is not something you choose — it is something you discover.

See my other posts about arousal and female orgasm:

To read more explicit things about female orgasm and pleasure, click here and visit OMGYes.

There is no better time in history to be a post-menopausal woman who wants to have a great sex life

Hundreds of women have told me, “I love my husband, but I am no longer interested in having sex.” Hundreds! Millions more are out there. More than 500 million women in the world are post-menopausal.  Many of these women still want to be interested in sex, they just aren’t.

Trisha was 62 years old when I first spoke to her about her sex life. Her drop in libido came with menopause, twelve years before. The change happened gradually, and sex with her husband became non-spontaneous and predictable—a once-a-week event, always at the same time in the same way—something like scratching a mutual itch, she said, “If we’re lucky enough to have the itch.” Although they’d had wonderful, compatible sex with each other for decades, it had become Boring,” she said, and we don’t do boring.”

Trisha had noticed this happening for a lot of her girlfriends— they were having less and less sex. “What I’ve seen with my friends is that because they’ve lost interest, due to menopause, they don’t feel motivated. They can’t see the point of revamping sexuality because from where they are, they don’t want to. What’s the point? They don’t feel sexy, they don’t feel horny, they don’t need sex anymore, so what the hell is the point of exploring it?”

Trisha was looking for options. Sex had been such an important and a strong part of her relationship with Ted, and they both wanted the spice back. She had high regard for Ted. ey had felt chemically attracted to each other from the time they’d first met in their twenties, and she wanted that back.

Part of the boring part for Trisha was that she used to orgasm during intercourse when she was on top, but she had not been able to do that for the past several years. Thee only way she could make it (have an orgasm) was through oral sex. In the past, she had been resistant to receiving oral sex. Once she began to experiment with it, she discovered how pleasurable it is, and she began to enjoy it. Still, she missed the variety of sexual options she’d previously had. Trisha signed up for my In the Bedroom class with the hope that it might help her figure out how to rekindle the spark she and Ted used to have.

When she told Ted she was going to take the class and why, it opened what she termed a scary conversation between the two about their current sex life. It was difficult and painful, but each of them found the courage and the honesty to say the hard stuff. They both admitted being bored with their whole pattern around sex. They agreed that sexuality was important to them, and that they were at a turning point. They were in their early sixties, and they both wanted to remain sexually active for another twenty or twenty- five years. Something needed to shift.

Trisha said that part of having the courage to broach this topic with Ted was she knew that they were supportive of each other. Neither was out to criticize the other. They both knew they wanted the same outcome: an exciting sex life. “It takes a lot of trust. Trust and knowing that you have faith in your partner, that you both want the same thing. It’s a huge, huge part of it,”Trisha said.

Whether your cyclical desire is gone due to surgery, menopause, or medication, there is a similar landscape to navigate. It is confusing, and can feel like a huge loss, sometimes devastating. One client, amidst tears and angry shouts, expressed how furious she was that no one had told her she would lose her mid-cycle interest in sex. She said she would have appreciated it more when she had it if she had known some day it was going to be gone. For women in a lesbian relationship at menopause, when ovulation stops, it can be doubly confounding, it is especially true if both women stop ovulating at or around the same time. With neither partner having that spontaneous cyclical interest, sexual initiation can drop sharply.

This lowering of libido is a common obstacle of menopause and the other one is the vaginal dryness which is often followed by sexual pain.   Trisha had the drop in libido obstacle, and she did not have the vaginal dryness. She got her libido back. Her story is below.

Highlighting her own femininity was central to Trisha sparking the change in her sex life. Her sex life had become boring, and so she came to my In the Bedroom series for help. At the end of the first class, I showed slides with pictures of ten low- or no-cost things a woman could do to spark an immediate sexual charge with her partner.

Ten Low to No Cost Things You Can Do to Spark an Immediate Sexual Charge

  • Stage your bedroom for a romantic event.
  • Make a sexual promise and keep it.
  • Interrupt your partner with one agenda only.
  • Give a sensual massage.
  • Break the rules.
  • Dress for sex.
  • Deliver a message written in lipstick.
  • Flash a body part, accidentally or with emphasis. Role play with characters you enjoy.
  • Send suggestive voice mails or texts – both ways.

Right after class, Trisha came up to me and asked if she could have a different assignment. “You need to understand, I don’t have any libido. I can’t do these things. I don’t have any desire for sex,” she said.

“Do them anyway,” I said. I wasn’t being unkind. I knew that the best way for her to find her libido was to take action. The following week Trisha was the first to raise her hand. She reported that she had done the assignment and picked something from the list, and she was shocked. She had dressed up in a sexy way, put on lipstick and eye makeup, and gone on a date with her husband. She flirted and they had fun. She already felt juicy again. “I was so surprised. I didn’t believe I could. I did all those things thinking nothing would happen. Now I am looking forward to sex with my husband!” Three months later, I followed up with her. She referred to her sex life as “hot.” “I did not know that I could control feeling horny through my mind, through thinking about sex, and through dressing up like I used to when I was sixteen or twenty-six and feeling beautiful. I think the key for me is really attention. Like you said, I can create that same feeling of hormonal need now, after menopause, by giving my attention to sex and feeling sexy. Part of all that is getting dressed up a little bit and going out somewhere in the evening, which we know isn’t the sexual part but we do it anyway. I like getting dressed up, knowing full well what’s coming later, and flirting, and making an event of the whole process so that I am feeling quite juicy by the time we even hit the bedroom. All of those things have rekindled my desire. I actually feel horny again!

Sounds kind of trivial and superficial to remember to dress sexily again. Luckily we have great bodies, so why not use them and dress sexily and not worry about the fact that I’m sixty-two years old, or believe that I should dress like sixty-two. No, I should not! To be the seductress in the bedroom, it’s the whole process—the way I dress and look, to the way the bedroom is decorated, to creating events, to having dates. Maybe going out for a six course meal, maybe going out for a martini, or something, but somewhere a little elegant.”

Overall, Trisha said her sex life has gone from boring to hot; in fact, her word now is “uninhibited.” She gives herself over to the experience of sex. Her mind quits and she allows her body to take over. ere is no control, and she can get lost in the experience. It feels like freedom and openness to her. It feels like coming home. She gets that luscious experience of oneness, the feeling that there is no separation between her and her husband. “I did a lap dance for him, which was great. I got dressed up and he chose the music, he arranged soft lighting in the room so it wasn’t too bright. The whole series (In the Bedroom) gave me permission to be erotic to do all that. It was wonderful. We went out together to get the stockings and the garter belt. He loves such things. And it’s just fun. It is about bringing the fun back in.” Connecting sexually has brought in more tenderness and respect. “We are both far more loving in the little ways throughout the day. It is just sweet. It really has improved in small ways which is lovely. There’s a wonderful sense of gratitude for each other. Our little secret of what we’ve done here together in the bedroom, which was a big step in intimacy, spills over to appreciation in all the other ways as well.” Trisha found that if she and her husband got into “work mode” for days at a time, they would schedule a date, and the good sexual tension returned. If Trisha missed sex first, she asked her husband to create a date. She liked it when he asked her to go on a date. His expression of desire for her added more romance, and she found romance arousing. There was another physical piece that added to Trisha’s pleasure. Ted’s erection had been getting softer in the past few years.  This is normal, though not desirable. They went together to see his primary care physician and got a Cialis prescription. Since using it, Trisha can orgasm again from being on top during intercourse. She had enjoyed this a lot in the past, and though she had added in oral sex successfully, having more variety of sexual positions was a positive.

Great Post-menopausal Sex is possible – the built in obstacles are navigable.  In part this is due to many different and safe treatments for the vaginal changes (Click here to read my other blog article on Vaginal Dryness), and the availability of Viagra like drugs and other products that are treatments for arousal problems.  It is also due to keeping your sexual vibrancy alive, which is not a drug. For Trisha, and many of my clients, it is doing the actions that keep the sparks flying.

How PCOS Can Affect Your Sex Life

Having PCOS is like being dealt a hand of genetic cards. You can play those cards so that you feel your best, sexually and in terms of your energy and mood. Your lifestyle, your diet, and hormonal management are all important pieces to manage the hand you have been dealt.

First thing to know is that you are not alone: one in ten women has a similar set of playing cards. PCOS (Polycystic Ovarian Syndrome) is a common genetic hormonal pattern in which your DHEA (an adrenal hormone) and your testosterone are robustly influential in relation to your ‘female’ hormones (estrogen and progesterone). Even though testosterone is widely accepted as the hormone of desire, if you have too much, you will not necessarily have a high libido. You may still have similar desire problems, or arousal and orgasm problems, as women without PCOS, though not for the same reasons. 

Twenty percent of the women I see in my practice have this hormonal pattern and I have found multiple things that work to balance you emotionally and physically, as well as improve your sexual experience. Let’s start with the basics, your period, and then go on to hear how PCOS interacts with your sex life, and what you can do about it.

With this hormone pattern women often experience problems with their periods—skipped periods, frequent periods, heavy bleeding, extra long periods, severe cramps, or no periods at all. Sometimes providers prescribe oral contraceptives to manage the pain and the bleeding, and to make the cycles regular. Women who have heavy and/or long periods can bleed so much that they become anemic. If you have anemia you can become so tired from an iron deficiency that you don’t have the oomph to be interested in sex. On top of that, it can seem to your partner that you are always on your period, and never available for sex. Misunderstanding around this can lead to distance and resentment in your relationship.

Even if periods are regular, with the extra androgen influence, women with PCOS are more likely to have cycles without releasing an egg. Without that mid-cycle hormone spike, you are less likely to experience the surges of desire, the ‘horniness’, mid cycle. Also, when you don’t ovulate you don’t produce much progesterone. Progesterone is the relaxing hormone in your chemical mix. You have estrogen and testosterone in that mix and those are both activating; progesterone balances that activation with relaxation. You have receptor sites in your brain for progesterone and when it lands there, you can feel mild sedation and calmness. When your progesterone level is low your sleep can be restless, you toss and turn, you can get sweaty, and you don’t wake up feeling restored.

Women with this hormonal pattern of PCOS report to me having night sweats, itchy or hypersensitive skin, and greater anxiety and irritability—sometimes too irritable to want to be touched. They also are, according to research, more likely to be depressed.

Also, If you have PCOS you are more likely to struggle with weight, and be at a higher risk of diabetes. The increase in testosterone increases the size of your muscles. Sometimes this works for you, and sometimes your muscles bulk up more than you want. This bulking up increases your weight and excess body weight can contribute to a lack of desire for sex. Many women who gain weight become self-conscious about their weight. It inhibits them from wanting to be seen naked, and so they refrain from initiating sexual contact.

Not all women with PCOS have or are going to have all of these symptoms. Many women with PCOS have no sexual problems, none at all. There is a large variation in how women with PCOS are affected. One third of women with PCOS will struggle with decreased fertility, and having sex will be linked with using ovulatory kits, and jumping in bed when the timing is ‘right’. Some women will have extensive medical workups for this and be on medications that influence their mood and desire. PCOS is not one thing — the underlying hormonal pattern of PCOS is there, but the expression is different. With genetic studies, we are still learning why this expression is so varied and how we can intervene.

Besides low sexual arousal and desire, women with excess androgen hormones can complain of vaginal symptoms including burning, dryness, or irritation. Some women report their own lubrication does not last long enough for them to finish sex without needing to add a lubricant. Sometimes there is ongoing itching and burning of the vagina that gets worse at certain times of the month.

Ann had this PCOS hormonal pattern. It was her anxiety and irritability that brought her in for a hormone evaluation. Specifically, it was the flush of embarrassment on her twelve-year-old daughter’s face when she, Ann, angrily demanded that the man in the ice cream truck turn down his annoying music. She recognized that her reaction was over the top and she was tired of being on the edge. On her intake form, Ann marked her symptoms— anxiety, irritability, vaginal dryness, specifically vaginal burning after intercourse, low libido, restless sleep, and worsening PMS. She had felt on edge for a few years and the number of days she felt moody was on the increase. Her sexual desire had been low for years. Vaginal dryness had started after the birth of her second child and was getting worse. Lubricants helped intercourse feel comfortable, but she was not that excited about having intercourse at all. She had sex because she knew it was important to her marriage, and she did like the closeness she and her husband shared after sex.

The vaginal dryness and burning that is sometimes found in women with PCOS is easily treated. Ann found this to be true. Eight weeks after she began treatment, her vagina felt back to the way it was before she had her second child. She no longer had dryness, and she no longer burned for a few days after being sexual. These vaginal symptoms responded quickly to the same estrogen treatment used for menopausal vaginal dryness : a topical low dose estradiol cream, or suppository used once a week.

Ann received a prescription of micronized progesterone, and with it she felt more relaxed and was able to sleep longer and deeper. She no longer experienced on the edge, moody feelings. She still felt anxious at times, but the feeling was slight in comparison. Her husband could approach her without her snapping at him. His touch, which had become annoying, felt good again. Intercourse was distress free, and she felt stronger levels of arousal than she had in years.

Ann did not have the anemia, but if she did she would have been given an over the counter iron pill to take daily and advised to increase the iron rich foods in her diet. About one third of women with PCOS have heavy periods. Heavy bleeding is defined, in medicine, as a need to change your pad or tampon every one to two hours. Long periods are defined as ones that last longer than seven days. Treat the low iron until your hemoglobin and hematocrit are in the normal ranges. Sometimes prescription iron is recommended. Also, if your provider doesn’t test your ferritin level (a measurement of stored iron), ask for it. Clinically, I notice women with ferritin levels greater than 50 report a stronger sense of wellbeing and are more likely to have some energy left for sex when they get into bed at night, than women with ferritin levels below 50.

Also, your health care provider can help you look at several treatment options to help you modify the heavy bleeding. Some of your options are friendlier to your arousal and libido than others. When your hormones are managed well, you will have more regular cycles, and probably lighter periods. You will discover you have more choices around which days to be sexual, and more energy with which to have it.

Remember, there is nothing ‘wrong’ with you and you are not alone. One in ten women are managing this too, and more genetic studies are underway to increase understanding and optimize health.

Symptoms of Too Much Testosterone in Females

  • Acne
  • Restless sleep/Insomnia
  • Irritability
  • Anxiety
  • Short fuse/Anger/Rage
  • Worse PMS
  • Menstrual Cramps
  • Weight gain/Bulking up
  • Irregular periods/No periods/Heavy periods 
  • Increase in chin and lip hair and hair elsewhere on body and a thinning of hair on top of the head
  • Vaginal irritation and/or dryness

This is an edited excerpt from Fanning the Female Flame-How to Increase Sexual Desire (without Changing Parters).

Birth control flattening your sex drive?

Heather was thirty-one when she first came to my office for help to locate her sexual desire. Her sandy blonde hair had an angled cut that came right below her chin. She walked in, sat down in the office chair right up against my clinic desk, and looked directly at me and said, “Tell me Susan, do women ever really want it?”

As she asked me that question, I took a quick breath as I registered what she was telling me—that she did not experience sexual desire, and that possibly she never had. Even though her particular medical situation has presented dozens upon dozens of times in my office since her visit in 2003, I will never forget the striking directness of her question.

Heather told me she’d never felt interest in being sexual. She did not think about sex or look forward to it. She never had. She otherwise had a very satisfying life. She was attracted to her husband. She found him to be exceptionally good-looking and manly.

Heather was healthy. She had no medical conditions. She was on no other medication besides the pill. Her life was busy and she enjoyed it. Mostly she stayed home with their three school aged kids, and she assisted her husband in his CPA practice part-time. Their daughter was eleven, and their twins (a boy and a girl) were nine. All of her children were well adjusted.

Her contraceptive history revealed that she had gone on the birth control pill in her late teens before becoming sexual. She was on birth control when she married her husband, and she had stayed on birth control pills until she wanted to get pregnant. She stopped to get pregnant and then started again when she stopped breastfeeding. She did this again for the second pregnancy when she had the twins. She had gotten pregnant quickly each time. At the time of her visit she was back on the pill.

Although highly effective at preventing pregnancy, birth control pills and other hormonal contraceptives are not always sex friendly. They can dampen sexual desire and reduce vaginal lubrication during sex, which can cause intercourse to become painful.

Research shows that while most women on the pill report no change in desire, some report more sexual desire, while others report less. I see those women who have less.

Here’s why some women see their desire drop. Hormonal contraceptives (including the pill, the patch, and the ring) prevent pregnancy by blocking ovulation, so that surge in hormones that comes with ovulation no longer happens. If you are used to experiencing a spontaneous interest in sex mid-cycle, you may notice that it is no longer there after you start using a hormonal contraceptive.

Also, hormonal contraceptives lower the testosterone level in your body. Testosterone, which is the primary hormone associated with sexual desire in both men and women, is produced less by your ovaries when you are on hormonal contraceptives. Also, the estrogen you are taking causes a liver protein called Sex Hormone-Binding Globulin (SHBG) to be increased. This protein binds up your testosterone, making the testosterone that you do have less available for your cells to use. Lowering your testosterone can land a blow to your sexual desire. It also can decrease lubrication, sensation, arousal, and weaken orgasm—all the feel good parts of sex. The Ortho Evra Patch, the NuvaRing, and also the newer, lower, twenty microgram estrogen birth control pills create even more binding up of testosterone than the older versions of the pill that had thirty or thirty-five micrograms of estrogen.

Heather’s blood tests confirmed her testosterone levels were below normal and she had an elevated SHBG level. I explained to Heather that this is a side effect of using the pill and it did not mean something was wrong with her.  

After our visit Heather decided to try going off of the pill to see what she experienced. Nine months later, she came in and reported that she had started feeling cyclical sexual desire about seven months after stopping the pill. This pleased her. She could finally relate to wanting it.

She never went back on the pill. Since both she and her husband were satisfied with their three children, he got a vasectomy.

Their sex life expanded. She continued to desire him, especially mid-cycle. She discovered a newfound appetite for exploration and discovery. They got creative in their lovemaking—they were sexual in the middle of the day and in different rooms of the house, they bought sex toys, and experimented with anal intercourse. They became far more open with each other and felt more connected.

Heather told me feeling sexual desire has made her feel normal. She’s no longer missing out! She finally felt part of the club of women who have desire and enjoy sex. She did not realize how much she had felt like an outsider before.

Some contraceptives don’t block ovulation or lower testosterone; these include the barrier methods—condoms, diaphragms, and also the PARAGARD® IUD (Copper-7). There is always the vasectomy option for your partner, or a permanent method for you, if you both are sure you don’t want any more children.

Not everyone is a candidate for these methods. Your medical history, your risk of pregnancy, and your personality all should be factors in your choice.

If you notice a drop in libido within a few months of starting any hormonal contraceptive, explore your options with your health care provider. The list of possible problem birth control methods includes the progestin only contraceptives like the Depo-Provera shot, the mini pill, and the implants in your arm, as a small percentage of women users may have lower libido and vaginal dryness with these as well. There is no perfect contraception, as each has its plusses and minuses.

If you do need contraception and your situation requires you to use a hormonal contraceptive that blocks ovulation or lowers your testosterone, there are remedies that can counterbalance those negative effects. Also, some birth control pills are found to be friendlier to your sex life than others.

This is an excerpt from Fanning the Female Flame-How to Increase Your Sexual Desire (Without Changing Partners).

 

Question: Do I need to get my testosterone level tested?

Signed, a woman with little to no desire for sex

Of the low libido women who come to see me, roughly two or three out of twenty will have testosterone levels low enough that I identify it as a contributing factor to their low sex drive. Could that be you? It is important for you to know the answer. The list below gives you a reasonable idea if you are a woman who should get tested. Check the symptom list — If your testosterone levels are low you most likely will have at least three or four of these symptoms. It won’t just be that you have no desire for sex. Testosterone affects your whole body, so low levels affect your muscles and your mood too.

Here is the list of things that can happen when your testosterone is low:

  • You feel tired
  • You have less endurance
  • Your muscles aren’t strong, and even when you work out you don’t get much result
  • Your mood is low, and you feel a physical kind of depression
  • You are less optimistic than you used to be
  • Overall sexual touch doesn’t do as much for you as it used to–there is a dullness to the sensations in your vagina and clitoris
  • When your nipples are touched you no longer get aroused
  • Your vulva can feel as if it is burning
  • Your vagina has tears in the skin after intercourse, or can occur spontaneously
  • You will have less lubrication in your vagina when you are aroused
  • The amount of hair on your body is less, and the quality of your hair is thinner
  • You aren’t thinking about or planning for sex
  • Your memory is not as sharp as it used to be

GETTING TESTED: If you have three or four of these symptoms then ask your provider to test your levels.

Tests should include a Total Testosterone, and a Free Testosterone. SHBG (Sex Hormone Binding Globulin) will also be calculated to figure out how much of your testosterone is available for you to use, as it can be bound by this protein. If your tests show that you are deficient (below normal range) or low normal (low normal is the bottom 25% of the normal range) you may be a candidate for treatment.

More about testosterone in my book: Fanning the Female Flame

Click here to read about how PCOS can affect your sex life.

In the coming weeks, I’ll be writing about how to treat low testosterone.

The Female Brain and Your Level of Sexual Desire

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Sexual desire is funny mystery. You want to be relaxed enough so that you can then enjoy a build up of tension. It seems like two different directions at the same time, yet that is how sex works. The following current medical research looks at these two directions:

MRIs were taken of the brains of women who have low desire. Their brain activity was compared to the activity in women without low desire. In the women with low desire, the area of the cortex that is involved in self-monitoring and has ‘inhibitory executive control’ showed hyper activation. This meant her YES for sex was dampened down, and she had built-in inhibition. This is not what most women want.

In medicine, low desire through one frame is seen as the result of an imbalance in the excitatory and inhibitory processes inside of us. These are biochemical processes. The imbalance is caused by too little excitement or too much inhibition or a combination of those two phenomena.

Neurotransmitters are one focus of what may be involved. For example, Serotonin is a neurotransmitter that stabilizes our moods, is calming, and promotes good sleep. It is also a key inhibitory factor in sexual desire. It weakens the ability of the excitatory systems in our bodies to be activated by sexual cues. Sexual cues are what trigger our arousal and get us activated sexually. You want to be activated to have a good time.

Medicine is currently looking at ways to intervene in this process by modulating these excitatory and inhibitory pathways through targeting of neurotransmitters. Bupropion (Wellbutrin), bremelanotide (possible brand name is Rekynda) buspirone (Buspar), and flibanserin (Addyi) are examples of the drugs being explored to activate. At this time only flibanserin (Addyi) has been approved by the FDA to treat low desire.   Of note, there are combination products under study now. A combination product of testosterone and buspirone has been designed and is not yet available in the US, and a combination of trazodone and bupropion is in development here.

There are non-pharmacological ways to influence neurotransmitter levels too!   Cuddling with your mate and spending time with girlfriends are two that are well known to increase your activating neurotransmitter levels.

In my blog post titled: “Women and Sexual Arousal” I talk about Addyi, click here to read it.

More coming on this topic in future newsletters.

Sex Doesn’t Have to be Painful

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“Treat Your Vaginal Dryness Early” are the words I would put on large billboards along I-5 and along other major highways in the US. I want to get the word out to women sooner about this common problem. Many women I see have waited months or years to seek treatment, and I cringe at the number of nights they have been in pain. Or the number of nights they are ambivalent about having sex as they face the no win choice of either “sex with pain” or “no sex”.

 

 

Treating women’s dryness early would reduce that personal pain and burning during and after sex, and it would do so much to maintain the closeness in marriages — the closeness that can wobble when this happens. So don’t wait. There is no reason to wait. Vaginal dryness, particularly menopausal vaginal dryness, is progressive. The earlier you treat it the better.

Treating dryness early would not only reduce sexual pain for women, it would also improve the capacity for arousal and the quality of the orgasms of millions of American women. On top of that it would add quality to the sexual experience of the women’s partners. As far as what it would do for relationships, well that is a lot. When a partner isn’t available for sex there is confusion, distress and sometimes a misinterpretation of the source of the problem. Treating dryness early would make this relationship chaos less.

Vaginal dryness occurs in more than 50% of women experiencing menopause. It also occurs in young women. Usually these young women are on hormonal contraceptives like the birth control pill, hormonal IUDs, and implants, or they have a hormone condition called PCOS (Polycystic Ovarian Syndrome). Significant sexual pain occurs in 10% of young women who go on the pill because of vaginal changes that occur from taking the pill. This intimate pain is quite a negative introduction to the new world of sexuality for these young women.

Whether vaginal dryness is due to the pill or menopause or other conditions, it is quickly and easily treated. Don’t wait. The symptoms of pain with intercourse or the feeling like you have a rug burn after sex, will resolve in six to eight weeks. And the treatment is safe. It doesn’t increase your risk of getting breast or endometrial cancer (links to the research on safety are included later in article).

There are multiple treatments for dryness, and there are a few new ones. Intra-vaginal DHEA is one that I reviewed in the last newsletter. More new treatments, including laser therapy, are gathering data now. Low dose minimally absorbed estradiol is still the go-to treatment for dryness. Below is the handout I give to women when prescribing this medication.


USING LOW DOSE MINIMALLY ABSORBED VAGINAL ESTRADIOL

You have been prescribed a vaginal estrogen preparation to use topically.

This prescription is to treat vaginal dryness related to loss of estrogen, or for some women it is to replace estrogen when “crowded out” by naturally higher levels of testosterone.

This is a prescription that you pick up at the pharmacy.

This medication is a low dose hormone prescription. It is different than a lubricant, and different than a vaginal moisturizer. You can think of it like a conditioner.

You do not use it before sexual activity.

The hormonal changes that occur to the vagina also affect the tissue around the opening of the vagina and the urethra (the tube that creates the passage where urine leaves your body). When a topical estrogen cream is prescribed, often the instructions are to take ½ the dose and apply around the opening of the vagina and the labia (lips) including the clitoris and clitoral hood. The other half of the medication goes into the vagina using the applicator from the pharmacy. You also can use your fingers to insert the cream internally.

If you are beginning the prescription, you will often be advised to use it daily for a week, then reducing to twice a week. It takes six to eight weeks for the tissue to get back to the thickness it had been before the hormonal change. When your symptoms are gone, you can reduce the prescription to once a week. If symptoms reoccur you can then increase again to twice a week. If you have been using it for 8 weeks and you still have dryness or pain, come back in — something else may be going on besides vaginal dryness.

Prescriptions for inside the vagina are also written for rings (Estring: this is a ring that is placed inside the vagina and releases low dose estrogen for three months) or suppositories (Vagifem or custom compounded suppositories). These methods deliver estrogen to the vagina internally. Often when a woman uses rings or suppositories internally she will still benefit from some estrogen cream applied externally around the opening of the vagina where more pressure occurs particularly with thrusting.

Compounded vaginal estrogens can be made in creams without parabens and propylene glycol and other chemicals that irritate when cracks or fissures are present, or when there is skin sensitivity. There are bio-identical options for both compounded and non-compounded prescriptions.

Vaginal Estrogens have not been shown to cause an increased risk of breast or endometrial cancer, or any other cancer. See the 2016 American College Of Gynecology guidelines here for women who have had Breast Cancer, and their use of estrogen, click here to visit.

The use of low dose vaginal estrogen and risk of stroke continues to be under study, and so far the Estring, and low dose topical creams show no increase in blood clots, click here to visit.


THE BOTTOM LINE: Don’t put up with dryness or sexual pain from dryness. Find out the cause and treat it until it is gone. There are many resources to help you be successful with this safe treatment, so if your provider doesn’t ask you, then you ask them for treatment.

Click here to read my article about why there is no better time in history to be a post-menopausal woman who wants to have a great sex life.