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Medical Insurance Coverage

As beautiful as the outcome of a couple’s sex therapy can be, a systemic problem stands in the way of this sort of therapy being broadly available. Sex therapists and urologists are concerned about managed health care and Medicare, which has meant that doctors rarely have more than six or seven minutes to talk to patients. As Dr. Perelman points out, how can the doctor, in a few minutes, “take a history, do a diagnosis, figure out what is going on with him, figure out what is going on with her? Does she need a referral to a gynecologist, does she need hormone supplementation, does she need to practice dilating herself so she might be a little more comfortable with intercourse?”

Medical-Psychological Combination Therapy

Understanding that just writing prescriptions and giving out pills isn’t enough for many people, Dr. Perelman wants to work with the pharmaceutical companies to develop and disseminate an easy-to-replicate, affordable model of therapy that provides both the medical options and the counseling in combination to create a sexual tipping point. He sees it applying to women as well as men, and he feels that due to the drop-off of men who regularly refill their prescriptions, the pharmaceutical companies may be motivated to fund such work. In a field dominated by penis fixers, it would be a huge paradigm shift to move into the areas of relational intimacy, especially male intimacy, which heretofore has been all but ignored.

The Women’s Part of the Equation

If it is the need to develop intimacy that is ignored in men, in women, especially older women, what’s ignored is understanding their sexuality. “The problem is that there hasn’t been nearly enough research done on women’s sexuality,” says Dr. Louann Brizendine, a neuropsychiatrist at the University of California, San Francisco. During our interview, Dr. Brizendine told me that several years ago she worked on a segment for CNN with one of her female patients who was around sixty-five. CNN wanted to explore the issue of women’s brain and sexual function during menopause. The news editors cut it. “They were okay with the estrogen and the ‘keeping the brain healthy’ aspects,” Dr. Brizendine told me, “but they didn’t wander into the sexual area that we had done. My patient was a little bit miffed. She felt it was really important for women to know that you can keep yourself and your body and your mind and your sexual organs healthy and have a good sex life with your partner even when you’re older and that it takes knowledge about what to do and what not to do.”

Dr. Brizendine smiled as she related one of the best things about women she sees who have crossed the menopausal divide. “The kids are out of the house,” she said, “and they are into the next phase of their lives, and that is about how they can maintain their brain function, their sexual function, their libido. They are still very much interested in sex, but so often they come to me with very out-of-balance hormones. There has to be a hormonal balance in your brain and in your sexual organs so that all the parts are working.”

Men’s sexual issues are visible, they are external, and they make up a large part of a man’s sense of himself, and perhaps that is partly why the research funds favor men. Women’s sexual parts are inside and may be neglected if—or as long as—doctors and researchers think that the erection is the be-all and end-all of sex. This is bad enough on a personal level, but it becomes a virtual nonstarter when it comes to studying older women’s sexuality.

Women’s Hormone Replacement

As you may recall, in 2000, the Women’s Health Initiative issued findings that hormone therapy (HT)—that is to say, replacing the decreasing levels of estrogen in women approaching menopause—did not prevent heart disease and, in fact, increased cardiovascular risk factors. The report hit like a bombshell and frightened untold numbers of women away from HT. In the view of the study’s critics, this has led to a generation of women suffering needlessly from menopausal symptoms, some of them acute, that could be safely treated.

The problem, as many experts have explained it to me, was that the study was misleading because the women participants were recruited from Medicare rolls, their average age was from sixty-three to seventy-nine, many were obese or smokers or both, and some two-thirds of them had never been on hormones before and thus had been estrogen-deprived for many years leading up to the study.

It is my understanding that the optimum time to begin HT is at menopause. Dr. Michelle Warren, medical director at the Center for Menopause, Hormonal Disorders, and Women’s Health at Columbia University Medical Center, told me, “If you start HT at menopause and continue with it, there is protection against bone loss and vaginal atrophy and probably some protection against heart disease and other problems that can occur before, during, and after menopause. Some recent data also shows that the death rate is decreased in women taking hormones, and that the increase in heart attacks is not significant. Recently, they went back and saw that for the women who had been on estrogen alone, the hormones were really protecting the heart. Additionally, the study showed that in the women who were given estrogen alone as opposed to estrogen together with progesterone, there was no increase of breast cancer after almost seven years. This fact got little attention. The absolute relative risk is very small—.8 per thousand per year. I don’t think the hormones are causing breast cancer. They may be fueling the growth of some atypical cells that are present in the breast, but the risk is very, very tiny. The estrogen-responsive cancers are very responsive to treatment, and after you stop the estrogen, the risk of cancer goes away.”

In their book
Successful Aging,
Drs. John W. Rowe and Robert L. Kahn cite the Nurses’ Health Study, which followed fifty-nine thousand women for sixteen years. They note, “The consensus of this research is that postmenopausal hormone replacement re-duces the risk of heart disease an average of 44 percent, and increases life expectancy by 3 years—a dramatic effect.”
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The study goes on to say, “For women with one risk factor for heart disease (such as smoking, hypertension, diabetes, or a sedentary lifestyle), the benefits of hormone replacement outweigh the risks. This holds true even for women with a first-degree relative (mother or sister) with breast cancer. However, the equation shifts for women with no risk for heart disease and two first-degree relatives with breast cancer. For these women, HT carries more risk than benefits.”
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According to its proponents, HT helps keep the brain healthy by preventing shrinkage, and it can lead to more brain-cell volume. HT can actually help the speed of brain functions, and studies have shown that when begun early in menopause, HT may be able to delay dementia symptoms. Additionally, say these advocates, estrogen helps preserve bone and works with other hormones to increase bone mass. The hormone also helps bones absorb calcium, but only as long as you use it: When you stop taking estrogen, the bone loss resumes. The Mayo Clinic does not recommend taking estrogen just to prevent bone loss, however, as the risks outweigh the benefits in many women.

Postmenopausal women who are not on HT and who are at heightened risk of developing osteoporosis are those who have suffered food addictions such as bulimia and anorexia, smokers, very slight women, those who have been particularly sedentary, those who have suffered from intestinal tract problems (which impede the absorption of calcium), and those who have experienced frequent fractures. These women should consider being screened for osteoporosis. The most up-to-date screening method is called a dual energy X-ray absorptiometry test (DEXA). It is rather expensive and is currently covered by Medicare.

Dr. Warren, like other gynecologists I spoke with, feels that it is almost inevitable that postmenopausal women who are not on estrogen will suffer vaginal dryness and atrophy. As she described it, “There are three layers to the vagina. The top layer completely disappears and the other two layers shrink, and you lose collagen as well, so the vagina starts to shrink.” There are also urinary symptoms associated with age due to thinning of the urethral lining. Dr. Marianne Legato, in her book
Eve’s Rib: The New Science of Gender-Specific Medicine and How It Can Save Your Life,
says that a reliable way for doctors to determine if a woman has enough estrogen is to “examine a sample of her vaginal lining under the microscope: A well-estrogenized lining is many layers thick.”
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If there is a lack of estrogen, the vagina will no longer be plump and juicy, but it can be treated with vaginal estrogen that lubricates the bladder as well. One medication that I use is Vagifem. It acts on the vaginal tissues only and is not absorbed into the bloodstream. Vaginal estrogen creams and a vaginal ring with estrogen are also available. Dr. Warren notes that the creams should be given in low doses and that both they and the ring are thought to be low-risk when appropriately used.

When women choose to take HT, those who have a uterus should take both estrogen and progesterone, to protect them from endometrial cancer; those who have had their uterus removed should take estrogen only. Besides strengthening bone and improving the skin, the hair, the brain, and the health of the vagina (which reduces pain during intercourse), HT may also increase sexual desire.

I strongly urge older women to have their blood tested for hormone levels, not just estrogen but free testosterone as well. Testing for free testosterone is not an automatic. You have to ask for it, as doctors are just learning to test older women for testosterone deficiency. In discussing the bottoming out of sexual desire in women,
The Psychiatric Annals: The Journal of Continuing Psychiatric Education
re-ported, “It has been postulated that, ‘No matter how hard a woman might try to assemble the building blocks of healthy sexual functioning—the required amount of the hormones, a loving partner, adequate stimulation, possibly a good sexual fantasy—it cannot work if she does not have the basic foundation of enough testosterone.’ ”
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Dr. Brizendine has been prescribing testosterone replacement for her women patients since 1994. She says that sexual dysfunction in women is often an above-the-waist matter, residing in the brain. The upsides of testosterone replacement are increased libido and the sensitivity of the genitals, especially the clitoris; heightened energy; and better mood, mental acuity, and muscle and bone growth. The downsides may include lower voice, facial hair, body odor, acne, and thinning hair. The particular form of testosterone that can actually get into your brain and cause an upswing of libido is known as “free testosterone.” The normal range of free testosterone for a woman—the amount thought necessary to maintain her sexual interest—is 20 to 70 of what are called picograms per milliliter. “Here’s the thing,” says Dr. Brizendine. “If you were to start taking estrogen in the form of an oral birth control pill or oral hormone replacement, it goes straight to your liver and makes more of this big, sticky globular protein called SHBG, or sex hormone binding globulin. I think of it as a big, sticky teddy bear that goes around in your bloodstream and gobbles up all of your testosterone, and then your testosterone isn’t free anymore. So you may have a good total testosterone level as a woman, but if you don’t have any that is free, you don’t have any that can get into your brain. The normal range for your sex hormone binding globulin is 100 to 150. If you are getting a workup for low libido, you want to know the level of free testosterone, because that is what counts in terms of your sex drive in the brain.” (Remember: The brain is the biggest sex organ.) Dr. Marianne Legato writes, “Before you take testosterone, make sure your doctor has measured your serum lipids and that your HDL (high-density lipoprotein or ‘good cholesteral’) is over 45 mg/dl.”
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The hormones can be administered in several ways. Some women, like me, prefer the estrogen patch. The Vivelle-Dot seems to be a favorite. These patches provide transdermal creams, which may not go through the liver as much as oral doses. The Vivelle-Dot patch is small and transparent; the only way you see it is because it’s shiny. It also comes in different concentrations. If you don’t want to wear a patch, there are now very good gels, creams, and a spray that deliver estrogen through the skin. It’s not true for all women, but I took oral estrogen for six years and it went right through me—didn’t even register when they tested my blood levels—and it was probably creating those sticky teddy bear–like globulin proteins from the liver that killed off all my free testosterone. But who knew? Then, for many years, I used a low-dose Vivelle patch twice a week. But when a noninvasive cancer lump was discovered in my right breast (and removed), I had to stop all estrogen therapy.

Some women prefer and benefit from oral estrogen therapy because their good cholesterol (HDL) goes up. For some, the estrogen by itself is enough to raise their sex drive. For others, some testosterone, either in patch or gel form, will jump-start their libido and increase their energy and sense of overall well-being. For testosterone gel, you smooth a nickel-sized blob on your abdomen or inner thigh. It doesn’t take long to experience the results. Talk to your doctor!

The type of doctor we need to turn to for HT should be an ob-gyn who practices postmenopausal hormone replacement therapy, as opposed to one who specializes in pregnancies and deliveries. Dr. Michelle Warren calls such doctors “menopause-friendly” and says they can be internists as well.

Human Growth Hormone

While we are on the subject of hormones, let me say a few things about human growth hormone (HGH), which has become a popular drug at many anti-aging clinics. HGH is naturally produced in the pituitary gland, at the base of the brain, and serves to fuel growth throughout childhood. Around the time a person hits thirty, the pituitary gradually reduces the amount it produces. Injections of synthetic HGH stimulate the pituitary gland to produce more of the hormone, and this can increase muscle mass and reduce body fat. But there are no free lunches. HGH can be harmful, causing aching joints, fluid retention and swelling, and carpal tunnel syndrome; most important, its long-term use may cause cancer by fueling the growth of small tumors. We won’t even go into how expensive it is! As I said in
Chapter 5
, many doctors believe that the best way to stimulate growth hormones naturally is to get enough sleep, because that is when growth hormone and testosterone production peak.