By Debra Gordon
Alan M. Altman, M.D., a Boston-based gynecologist, makes it a point to ask his patients the one question many doctors avoid like a tax audit: "Are you sexually active?" And he doesn't stop there. If she says yes, he asks if she's having any problems or has any concerns. And if she says she is not sexually active, he asks: "Does that bother you or your partner?"
"I can't tell you the number of women who sat speechless with that second question, looked at me, then broke down and started crying," says Dr. Altman, assistant clinical professor of obstetrics, gynecology and reproductive biology at Harvard Medical School, and the author of "Making Love The Way We Used To ... Or Better" (Contemporary Books, 2001).
No surprise. Surveys show that one in three sexually active women are dissatisfied with some aspect of their sex life, Dr. Altman says in his book. But unlike their mothers -- who typically also found their own sexuality lagging as they aged -- today's generation of women isn't prepared to relegate great sex to a fond memory.
"These are the Baby Boomers," Dr. Altman says. "Having started one sexual revolution in their college years, they're now on the cusp of a second one, in which the old myths about sex and aging are destroyed."
So they want to know where the passion went, and they want it back. The Midlife Women's Health Survey, conducted by researchers at Pennsylvania State University, surveyed 505 women aged 35 to 55 and found most felt they were more deserving of a good sex life now than ever before in their lives.
So why aren't they getting it?
"It's multifaceted," Dr. Altman says. "A woman in her forties is in the midst of what I call the 'taffy-pull' of life. She's dealing with parents who have health issues, her partner and the normal relationship issues there, kids, a job. She's going in six or seven different directions. That's going to impact her sex life."
Dr. Altman breaks the reasons into two main categories: physical and emotional. Emotional reasons include the aforementioned taffy-pull, but also the reality that, after 15 or more years, most relationships grow stale. "It's fun to eat at a restaurant that's really, really good," he says, "but if you eat there every night, it gets boring. Sooner or later, there's a sameness to a relationship no matter who you are."
To counter that, women have to identify their own needs -- both in and out of bed. And men have to pay as much attention to intimacy as they do to sex. "Men are linear: They get turned on, move onto sex, reach orgasm," Dr. Altman says. "Women are more complicated. They may not even have the desire until they're stimulated. They're more circular." Hence, intimacy, also known as romance, typically goes the way of size 6 pants and three-times-a-day sex.
Get it back, Dr. Altman counsels. Once intimacy returns, he says, many women find the desire does, too. One way to reinvigorate your marriage, he says: Do the unexpected. That could mean a quickie in the dressing room at Bloomingdale's, renting a hotel room just for the afternoon, or even just kissing more -- perhaps while feeding your partner strawberries!
Often, however, the trouble isn't in your head, but in your body, Dr. Altman notes. Physical problems account for an estimated 90 percent of sexual problems, he says. And we're not just talking male impotence here.
Even fatigue can be due to more than just three kids, a full-time job, the dog, cat, PTA and coaching the traveling soccer team.
For women in their late thirties and forties, it may be related to perimenopause, Dr. Altman says, that period before menopause that can wreak havoc with every part of her body, from how she sleeps at night to how interested she is in sex. And the kicker? Perimenopause may begin as many as 10 years before menopause.
Fatigue can result from fluctuating estrogen levels, which interrupt REM sleep, the most restorative phase of sleep; cause night sweats a woman might not even be aware she's having; and affect bladder muscles, waking her several times a night for bathroom runs.
Those same fluctuating estrogen levels also can lead to painful intercourse, as low estrogen levels cause dryness of the vaginal tissues.
But perimenopause also affects another hormone, one many women may not even realize they have: testosterone. A growing number of studies link testosterone to libido, and yet between the ages 20 and 40, it's estimated a woman's testosterone shrinks by half.
"Most of what we used to think of as being psychological problems are, in fact, physiological," Dr. Altman says. "It's a natural area for a gynecologist to get into."
Yet when he lectured to a room full of 2,000 researchers and doctors at the North American Menopause Society last year, he told the group that at least half the women in the audience were low in testosterone and didn't know it.
Chances are, their doctors aren't going to tell them about it either. Most physicians, Dr. Altman says, simply don't have the time to talk to patients about their sexual lives. Even if they did have the time, he says, many, particularly older doctors trained in the 1970s and earlier, don't know all that much about normal human sexuality.
"I was graduated from New York University with my M.D. in 1975," Dr. Altman says, "and we were the first class to have a sex education class as part of our training."
He recalls a lecture he gave last year at a statewide conference of ob-gyns. Despite dozens of talks on everything from menopause to genital cancer, there was not one session on sexuality the entire meeting.
So it may be up to women to start the discussion with their doctors, he says. Several remedies that may help with dragging desire -- including supplemental estrogen, progesterone, and testosterone -- can be right there in the physician's prescription pad. But there also can be several causes in that same prescription pad. "Say to your doctor, "I really do need to talk with you about my libido or my ability to achieve an orgasm," Dr. Altman says. "If you're threatened by the response, or your doctors brushes over it, you should find another doctor or someone else who can talk about sexual issues."
As for that statewide ob-gyn society, they've invited Dr. Altman back to talk about sex.