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man and woman in bed, separated, unhappy

Study Shows that Deep Dyspareunia can Improve with Interdisciplinary Treatment

There is good news for women who are suffering from Deep Dyspareunia! Dyspareunia is the fancy medical term for painful sex, and can be categorized two ways: superficial (affecting just the entrance of the vagina or vulva), or deep (pain during deep penetration).

In a recent study published in the Journal of Sexual Medicine, researchers had 278 women self-report pain scores related to their Dyspareunia symptoms on an 11-point scale. The women and their physicians decided which treatment options to pursue, including “minimally invasive surgery, hormone therapy, pain education, physiotherapy, or psychological therapy” (ISSM). This is what is considered an “interdisciplinary approach,” since treatments were not limited to one course of action.

After a year, researchers followed up with the women who participated in the study and found that the 28% of women who had reported absent or mild pain had increased to 45% of women, the 17% who rated their pain as moderate increased to 25%, and the 55% of women who said they were experiencing severe pain decreased to 30% of women. These are great results and should give hope to women who are still experiencing painful sex!

It should be noted that having depression and being at a younger age were considered predictors for having continuing deep dyspareunia after a year, because depression can also “affect the sexual response cycle, pelvic floor function, relationships with partners, and emotional aspects of pain” (ISSM). More research needs to be done about how depression can affect deep dyspareunia, but the authors of the study recommend treating your depression first and foremost should you be suffering from it, as your other symptoms can improve with that treatment.
Because the women and their doctors chose different plans of action to treat the symptoms, we can’t be sure exactly which treatments were most effective, but the bottom line is that after only a year your symptoms can improve if you are able to attack the problem holistically. That’s where we come in. IntimMedicine Specialists are well-known for our holistic, tailored approach towards treating our patients. If you are experiencing painful sex, give us a call, or e-mail us! Our experts here in Washington, DC would love to discuss which options to try with you to start treating your pain and improve your sex life and beyond!

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older couple embracing and smiling

Sexual well-being is an important part of any person’s life, and when things aren’t going well or working right, it can be embarrassing and difficult to talk about with your sexual partner and your doctor. But it doesn’t have to be, and your life does not have to be dictated by sexual dysfunction. Below are a few common problems you or your partner might be experiencing. Read on to learn what to do to make an appointment with one of our sexual medicine specialists!

LOW TESTOSTERONE

It is true that a man’s sex drive decreases as he ages due to a natural decline in testosterone over the course of his life. But, sometimes testosterone production slows down too fast, resulting in low testosterone, or Low T. Low T can be connected to Erectile Dysfunction (ED), but it is not always the cause of ED. Low T is also connected to heart disease, obesity, diabetes, and depression. If you are experiencing a reduced sex-drive as well as weight gain, depression, and irritability and brain fog, you might have Low T. Fortunately, our team of specialists are on the cutting edge of testosterone replacement therapy and we’ve got you covered.

ERECTILE DYSFUNCTION

Erectile Dysfunction (ED) is difficulty getting or maintaining an erection firm enough to have sex, and it has many causes. It can be caused by problems with blood flow due to heart problems, high blood pressure, or heavy smoking or alcohol use, all of which can contribute to damage to the blood vessels that create the blood flow into the penis, resulting in an erection. It can also be caused by nerve supply or hormone levels (see Low Testosterone above). Sometimes it is psychological, or it’s caused by interference from prescription drugs. Because Erectile Dysfunction can be caused by so many things, you’ll want to talk to our specialists about what might be causing it in your case. Dr. Rubin at IntimMedicine Specialists is a urologist with fellowship training in Sexual Medicine and performs extensive testing unique to each patient’s individual needs. Fortunately, ED is treatable! From behavioral changes to medications, hormone replacement therapy (HRT) to penile implants, there is a solution out there for you.

STRESS OR DEPRESSION

Low sex drive or erectile dysfunction are often linked to stress and depression, either resulting from it or causing it. Talk to us about what’s going on in your life. Our holistic approach includes treating each patient as a whole person, with every aspect of their lives in mind. If stress or depression is a symptom of sexual dysfunction or is causing it, we are here to listen and to help you get relief from it.

None of these symptoms or sexual problems should rule your life. Often, men report depression and relationship problems that stem from sexual dysfunction. Don’t let these problems keep you from enjoying your life! The good news is that our very own urology specialist Dr. Rachel Rubin is on the cutting edge of today’s urology procedures and practices, and she is ready to listen and help create a treatment plan specifically for you – call 202.293.1000 to make an appointment with Dr. Rubin in the Washington, DC area to get your confidence and your life back today!

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holding hands

Ever since we were infants, skin-to-skin contact meant closeness, calm and intimacy. So when disorders of the skin like Psoriasis interfere with such an important sexual organ (the skin, our largest by far), there are consequences. Psoriasis is more than a skin condition; it can affect everything from your self-esteem and your mood to your sexual health and well-being. According to a recent study, psoriasis is directly linked to sexual dysfunction and erectile dysfunction. But, it doesn’t have to be that way.

Psoriasis is an autoimmune disease, which means the body’s immune system attacks itself. With psoriasis this means the white blood cells known as T cells attack the skin cells, causing your body to over-produce skin cells and resulting in the red, scaly pile-up of skin cells, or plaque, that is associated with psoriasis. Psoriasis is genetic and non-contagious, but nearly one-third of people with psoriasis report that it has a negative effect on their sex lives.

Psoriasis flare-ups usually occur on a person’s hands, feet, face, neck, scalp, and in the joints, but have also been known to affect the genital area. Having psoriasis is sometimes embarrassing; if you are having a bad flare up it might make you want to stay covered up and avoid intimate situations with a partner, and having a flare-up on your genitals can make sex physically uncomfortable if not impossible.

Depression and anxiety are also more likely for people with psoriasis because the disease can be frustrating to treat and can affect one’s self-esteem. Stress can cause flare-ups, which can lead to more stress, and it might seem like you’re caught in a never-ending battle with your psoriasis. All this can make it difficult to seek out or be receptive to sexual intimacy with a partner.

Does this mean if you have psoriasis you can’t ever hope to have good sex again? Of course not!

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woman, thoughtful

  New research published this month on the JAMA Network Open indicates that 7.0% of women and 10.3% of men have what is now classified as compulsive sexual behavior disorder (CSBD). CSBD is defined as “failing to control one’s sexual feelings and behaviors in a way that causes substantial distress and/or impairment in functioning.” There are a few things we can glean from this data, but it might tell us a whole lot more about our society than it does about human sexuality.

  First off, the results are self-reported and based on perceptions of one’s own behavior. Negative stigma about sexual urges or thoughts within certain cultures and sub-cultures in the United States could result in what researchers are now calling a disorder, but might actually be healthy urges interpreted through an unhealthy social lens. Psychologists have argued about what constitutes “healthy” sexual behavior since the dawn of the field, and the discussion is nowhere near a conclusion. Unfortunately, using a self-reporting survey does not allow researchers to be able to distinguish between participants feeling distressed about compulsive and intrusive sexual impulses, and participants feeling distressed about their sexual urges because of moralistic pressures within their sub-cultures.

  Secondly, the close percentage of men and women who are now diagnosed with CSBD could be telling, or it could not be. The long unspoken “rules” about male and female sexuality in the US could be at play here. Men have been told that their sexual urges cannot be repressed and that it is unhealthy to do so, while women have held the role as “sexual gatekeepers.” Those societal factors and gender roles may have led to fewer men and more women reporting distress due to their sexual urges and behaviors. On the other hand, it could be interpreted that men and women actually have similar sex drives and sexual habits. With interpretations of sexuality in America in such a complicated place, it is difficult to make a determination about this.

  The bottom line is this: if your sexual behaviors or urges are causing you distress or impairment in functioning, whatever that means to you, it is worth talking about! It is our goal to help you feel whole and healthy, and we believe sexual health and wellness is a huge factor in achieving that goal. Give us a call at 202.293.1000 or email info@intimmedicine.com to make an appointment with one of our specialists today. We are here to help.

 

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Exploring the Relationship between Food and Sexual Desire, and Food and Sexual Satiety (Part 2)

By James A Simon, MD, CCD, NCMP, IF, FACOG

In part one of this blog series, I focused on the profound impact obesity has on health generally. Literally every organ system in the body is affected. This includes reproductive organ cancers (i.e. breast, uterus, cervix and prostate) which demonstrate a significant increase in the number of cases and their severity in overweight and obese individuals. The costs to society are extraordinary. For example, the total cost of diabetes alone in the US was $327 billion (not a typo) in 2017, a 26 percent increase over the previous five-years (http://www.diabetes.org/advocacy/news-events/cost-of-diabetes.html). In this blog post (The Masturbation Diet Blog (Part 2), I want to zoom in on the impact of overweight and obesity on reproductive processes.

Weight gain over the reproductive lifecycle in women is incredible. For example, the percentage of US women with a body mass index or BMI of =25 kg/m2 (the standard definition of overweight individuals) increases from 56% for women aged 20-40, to 66% in women aged 40-60, and further increases to 74% in women aged 60-80 years. Yes, 3 out of 4 women aged 60 years and older are overweight or obese. Yikes! Further, the increase in “midlife spread” is focused in that stubborn truckle fat or visceral fat which carries with it changes in metabolism known as the metabolic syndrome (see below) which can increase heart attacks and strokes. (Flegal KM et al. JAMA. 2012;307:491-497.). When overweight and obesity affects a pre-pregnancy women, it can reduce her fertility (even with in vitro fertilization/”the test tube baby procedure”), and cause sexual dysfunction. When that women is pregnant, overweight or obesity can result in a greater risk of early miscarriage, congenital abnormalities in the baby, high blood pressure during later pregnancy (pre-eclampsia), added risk of the baby’s shoulders getting stuck during vaginal delivery (shoulder dystocia), and even the risk of a required Cesarean delivery. And women who tend to have excessive weight gain during pregnancy seldom lose it all, adding even more weight with each subsequent pregnancy.

In no case is the imbalance between one’s sexual appetite (too little) and one’s appetite for food (too much) more disproportionately affected than in overweight and obese individuals. Overweight and obese men have a 30-90% increased risk of erectile dysfunction (ED) compared with normal weight men. Women with the metabolic syndrome due in part to overweight or obesity (see above) have an increased prevalence of sexual dysfunctions as compared with matched control women. Lifestyle changes aimed at reducing body weight and increasing physical activity can improve both erectile function in obese men and arousal (lubrication and genital tingling) in women. The Mediterranean-style diet might be effective in ameliorating sexual dysfunction in women with the metabolic syndrome. (Esposito K, Giugliano , Ciotola M, et al. Obesity and sexual dysfunction, male and female. Int J Impot Res. 2008 Jul-Aug;20(4):358-65.)

Most importantly, we can now change the balance, that is, increase the desire for sex while decreasing the desire for food. Really? Yes! Deep in the brain, the hypothalamus and surrounding neural networks are the control center between desire for sex and desire for food. Let’s think evolutionarily. When there is famine (there are no famines at the Safeway, Publix, or Kroger these days), and associated severe weight loss, or starvation etc., reproduction stops. No menstrual periods, no hormones to trigger sexual appetite, resulting in low libido and little or no sex. Similar processes occur when a women is breast feeding. She is living off her “baby fat,” and in the process losing calories as she breast feeds the baby. The balance in the hypothalamus is likewise turned against sex, it’s all about the baby, the hell with sex, as Mother Nature didn’t want another pregnancy too close to the last one. Further if there is sex, it’s usually very painful because the imbalance in hormones is also focused on the health of the baby, not healthy genital tissues…and if there is pain with sex, well that’ certainly a disincentive for more sex.

These natural phenomena: the impact of weight (too low or too high) on sexual reproductive/function in both men and women, extensive research into the mechanisms controlling one’s appetite either for sex or for food, informs us on how to modify the balance between these two natural desires. We call that The Masturbation Diet, a counseling program in the area of sexual activity, wellness, and nutrition where we can help get the balance corrected.

In The Masturbation Diet Blog (Part 3) we’ll talk specifically about these controls and how affect the balance.

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Amused young African American couple sitting and hugging

Amused young African American couple sitting and huggingAs most of us know, a great relationship doesn’t start and end with sex. But a healthy sex life does form an integral part of it. In fact, almost 80% of men and 66% of women view sex as important to their relationships. And research shows that when one’s sex life is assessed as “good”, it adds 15-20% positive value to a relationship. But when one’s sex live is reported to be “bad or non-existent”, it plays an inordinately powerful negative role, draining the relationship of its positive value, by 50-70%!

And for the critics out there, it’s important to note that sex isn’t just physical. It’s an opportunity to express feelings that words cannot … an emotional experience that brings you closer with your partner … and, for some, the ultimate expression of their love. Not only does it foster a unique closeness, it can also provide comfort in times of stress, anxiety or other troubles. And it can help to keep things fresh and exciting, as couples “rediscover” each other through varied forms of sexual expression.

Timing and Frequency
Unfortunately, “importance” can be very subjective. While one person might view daily sex as crucial, another might think they’re doing a pretty good job fitting it in once every week or two. As long as a couple is on the same page, there are typically no problems. If it works for both of you, great! It’s when there is a difference in opinion that problems begin to arise.

Sex Drive Compatibility
If one person has a higher sex drive than their partner, they can start to feel unfulfilled. The other partner may wonder what the big deal is. (“Come on, it’s just sex!”) But for the unfulfilled partner, it can be a huge deal. They may begin to feel unwanted or unloved, and may even turn to sex substitutes, such as food, alcohol, drugs, even infidelity. Or they may just become angry and resentful. As a result, the relationship starts to suffer on all levels, which in turn, leads to even less sex, thus perpetuating a vicious cycle of conflict.

Making Time
The key to a healthy sexual relationship is often compromise – whether you’re the one who occasionally has sex when you’re not in the mood, or the one who goes without for a few days. Another key is being proactive – trying new things in the bedroom, seeking counseling, or simply making time for sex. There are a number of things that can slowly but surely erode your sex life – from busy schedules and kids to aging/changing bodies and lack of communication – but if you make sex a priority (instead of letting it become the white elephant in the room), you can keep the passion alive and your relationship healthy.
Interested in women’s sexual health? Contact us for an appointment.

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I’m pleased to share with you some exciting news about a treatment for low sexual desire that has an unintended consequence you may actually appreciate–weight loss. Some patients reported that after using flibanserin for as short as 8 weeks, that they began noticing that their clothes were looser and the number on the scale was surprisingly lower. Sounds too good to be true, I know, but let’s take a look at what flibanserin is and how it affects the brain.  Flibanserin is a serotonin 1A receptor agonist and a serotonin 2A receptor antagonist, which influences biological and neurological processes. While its primary effect is to increase sexual desire, it also has an impact on anxiety, appetite, memory, mood, and sleep. Researchers found that this treatment reaches the part of the brain that experiences sexual desire, but it may also impact satiety, that feeling of fullness at the end of a meal. Unlike some weight loss medications, there appears to be no weight regain with flibanserin (at least for about 18 months of study). More research will help us learn more about these effects, both sexual desire and weight, over the long term, but this is considered clinically meaningful in my book.

Flibanserin was first approved by the Federal Drug Administration (FDA) in August 2015 for low libido in women and was immediately dubbed the “female Viagra” although that is a misnomer.  Viagra treats a blood-flow issue to the penis, a physical issue, not desire which is an issue of the mind. For most women, sexual desire starts “north,” in the brain.

The Science Behind Improving Sexual Desire
Flibanserin was originally created as an antidepressant and although it didn’t work very well for depression, patients noted a pleasant side effect, an increase in sexual desire. It went back to the lab for further research, leading us to this moment in a new sexual revolution for premenopausal women. Considering that many women experience sexual dysfunction at some point, it is worth going for an evaluation with your doctor, ruling out extenuating circumstances (i.e., relationship problems), and see if this loss of desire is an actual diagnosable disorder, hypoactive sexual desire disorder or HSDD. If it is there is a solution.

Optimal Timing and Dose
The effectiveness of the 100 mg bedtime dose of flibanserin was evaluated in three pivotal 24-week trials of 2,400 premenopausal women with hypoactive sexual desire disorder (HSDD), otherwise known as “not ever in the mood for sex…ever!” The average age of women in the trials was 36 years, and these women had experienced diminished sex drive for about five years. While many have said that this medication only works in a small percentage of patients, and only has a little benefit at that, our experience is that those who respond do so in 8 weeks, and really recognize the difference. However, flibanserin has not been shown to enhance sexual performance in normal women, but it’s a starting point for women who have not been able to put a name to their low sexual desire condition, or have not found an effective treatment.  Additional treatments such as vaginal estrogen and or testosterone may be used for physical issues such as vaginal dryness or pain with intercourse.

Flibanserin is not without some side effects such as dizziness and in a few cases, lower blood pressure. But taken as directed, specifically, at bedtime, and without alcohol, you may be in for a satisfying sexual experience and some weight loss, which you will be thankful for all year long.

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penis_0For those who read, Part 1, sorry to leave you hanging (pun intended) last week. 

This time, yes, I am talking about penis size. For men, it is often all about size, thus the term “penis envy”. But for women, the penis is perceived as just another masculine feature, like muscles, a flat stomach, or being tall. If women do have a focus on a particular physical part of the male anatomy, it’s most likely to be the buttocks, a subject I will save for another time. (See, for reference: A Billion Wicked Thoughts: What the World’s Largest Experiment Reveals about Human Desire by Ogi Ogas and Sai Gaddam; Putnum Group, 2011)

The availability of abundant, free Internet sexual content portraying men with huge penises as “the norm” has created a bit of a one-eyed monster, if you will. I have now seen a significant number of female patients who have completely unrealistic expectations for the penis size of their partners, not to mention, a skewed idea of how long their partners should be intimate without breaking a sweat or ejaculating. Some women have actually done the unspeakable, telling their partners, ”Your penis is so small!” Ouch! Talk about hitting below the belt.

Pornography, which is the portrayal of sexual subject matter for the purpose of sexual arousal, has created such common, unrealistic expectations (beyond penis size) that it has actually spawned an excellent TED talk, as well as a “realistic porn” site: Make Love Not Porn.

So, if you imagine, even for one minute, that a Genoa-salami-sized-penis is “normal,” here are the actual facts: The range of erect penis length for most men is 5 – 6.5 inches. The circumference of the average man’s erect penis is 4 – 5 inches. This means the corresponding erect penis diameter is 1.27 – 1.6 inches. This size information has been confirmed multiple times among different ethnic groups and populations with only minimal variation (www.kinseyinstitute.org/resources/bib-penis.html or https://en.wikipedia.org/wiki/Human_penis_size).  While these sizes “are only numbers,” and as they say “a picture is worth a thousand words,” there is actually some good pictorial information that can provide meaningful visual perspective.

So, while fantasy is fine and actually very healthy, the reality of having sex with Jonah Falcon, the man with the world’s largest penis (a giant, freakish, colossus of 13.5 inches in length), could be completely terrifying! The takeaway here, Ladies and Gentlemen, is to be careful what you wish for, because you might not know what to do with it should you get it.

Interested in women’s sexual health? Contact us for an appointment.

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glansNo, this post isn’t about penises or vibrators. (Why do our minds always go there!) I’ll reserve that subject for Part 2. This is about the clitoris. Yes, the clitoris, “a small erectile female organ located within the anterior junction of the labia minora that develops from the same embryonic mass of tissue as the penis and is responsive to sexual stimulation” (according to Merriam-Webster on-line dictionary). While seldom the subject of much scientific research, a recent publication* investigated the relationship between clitoral size and sexual function (including the extensive internal portion – “out of sight, out of mind” you might say).

In a small convenience sample of women having a pelvic MRI for other reasons (such as fibroid tumors), these researchers compared clitoral size and each woman’s sexual function as measured by several validated scales. Paradoxically, women with the smallest clitorises (yes, that’s the correct pleural of clitoris), specifically the clitoral body and crus (see diagram below), had the best sexual function. Those women with a smaller clitoris tended to have better desire, arousal, lubrication, and orgasm. The authors of the study suggest that a greater density of nerves, basically squeezing the same number of nerves into a smaller space, is what leads to better function.

There are several limitations to this study, so take these findings with a grain of salt. The relatively few women who participated were having their MRIs done for other medical reasons besides participation in this sexual function study. Therefore, the findings may not actually be generalizable to all women, especially “normal” women without another existing medical condition. But, this study does give a whole new potential meaning to the oft-quoted “good things come in small packages” idea.  And that’s c.o.m.e., not c.u.m! Really, does your mind always go there?

Interested in women’s sexual health? Contact us for an appointment.

 

* Vaccaro CM, Fellner AN, Pauls RN. Female sexual function and the clitoral complex using pelvic MRI assessment. European Journal of Obstetrics & Gynecology and Reproductive Biology 180: 180–185, 2014.

 

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fda approved addyi todayDear Patient, Supporters and Friends,

Today the FDA made #HERstory for women with the approval of a first-ever medical treatment option for women’s most common sexual dysfunction, known as Hypoactive Sexual Desire Disorder, or HSDD. You can think of this disorder (HSDD) as: distressing low desire that can affect a woman, her partner or both and that lasts and lasts and lasts for more than 6 months regardless of circumstances, mood, vacation, health, etc. After enjoying normal sexual function, and then totally losing one’s interest in or desire for sex for longer than 6 months gives you some idea of the scope and impact of HSDD.

I know all of you have been closely monitoring the national conversation over the “little pink pill” or the “female Viagra” during the last year as the drumbeat has built among organizations such as ours – and among hundreds of thousands of people across the country – for treatment options for a condition that the FDA itself has recognized as a key unmet medical need. We at James A. Simon, MD, PC have been actively involved in the development of Flibanserin, or its new trade name ADDYI, for many years and have conducted several of the clinical trials used for FDA approval right here in the Washington, DC, office. For those of you who participated in those clinical studies, we want to personally thank you. Whether you received the active treatment in those trials or the matching placebo, soon you will be able to take “the real thing.”

James A. Simon, MD, PC is proud to be a part of such a thrilling moment in women’s sexual health and for the 16 million American women currently living without a single FDA-approved medical treatment option for HSDD.

With the FDA’s action today, The Agency not only approved a first-ever medical treatment option for HSDD, it also demonstrated that there IS a viable regulatory pathway forward toward approval of additional therapies for this and other female sexual health indications. Further, Flibanserin’s (ADDYI’s) approval today, opens the pipeline for other future options yet to come for women’s sexual health. In that vein, we are currently conducting additional studies on other medications for female sexual dysfunction right here at James A. Simon, MD, PC, and we are always looking for qualified study subjects/volunteers.

Women with HSDD deserve the safety and peace of mind that comes with access to FDA-approved medical treatment options, and today we write a new chapter in the fight for equity in sexual health.

Sincerely,
The entire James A. Simon, MD, PC family

 

Interested in women’s sexual health? Contact us for an appointment.

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