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A TALK TO SHARE WITH YOUR PATIENTS

Hormones, Sexuality, and Life—How Do Lust and Love Change With Age?

By Barbara S. Levy, MD

Medical Director, Women’s Health Center, Franciscan Health System, Federal Way, Wash., and member of the OBG MANAGEMENT Board of Editors

This is an edited transcript of a keynote address that Dr. Levy delivered at the 5th Annual Women’s Health Experience (WHE), October 11, 2008, Cincinnati, Ohio. WHE is a presentation of The Foundation for Female Health Awareness (www.womenshealthexperience.com).

Let's spend a little time talking about hormones and sex and life. Because, after all, there’s no life without sex and there’s not a lot of sex without hormones. So, let’s see if I can’t put some of that together for you and make some sense out of some of it. I’m going to start with a little story.

I understand that you had a storm here recently and lost power. So I’m going to start my story with the first day the power was out. There’s a couple—they slept through the alarm. School was still in session, but nobody got the kids up. The dog was on the bed, made a mess in the middle of the floor. They wake up and it is a half an hour later than it should be. He’s got a meeting with his boss that day. He laid out his clothes and everything was all set and the dog sat on the clothes. The shirt’s not clean. He’s not starting out with a very good day. She’s trying to get the kids ready for school. Nobody’s made their lunch, nobody’s made breakfast.

Long story short: Getting out of the house is not a pleasant experience that morning. Everybody’s running around ragged, and the rest of the day goes the same way. The meeting with the boss doesn’t go well. Everybody’s late to work. Kids were late to school. Mom doesn’t get her stuff done. They come back home and, of course, nobody laid out anything for dinner, so dinner’s not ready and the kids are whining, complaining. It’s not a wonderful experience.

They finally get everything organized supposedly for the next day—the kids’ homework, the cookies baked that somebody forgot to tell mom needed to be done by the next day. (That’s never happened in my household! Yeah, it happens, right?) The woman finally gets into bed about 10:45 PM, and what does she do? She curls up in a ball, and says “Oh, thank goodness, finally a few minutes to just be by myself.”

Now the husband has had a lousy day, too. Nothing’s gone well. There wasn’t anything good for dinner. They had leftovers again. Things didn’t go well with the boss. He was off playing softball after work (he wasn’t home taking care of the kids). But that didn’t go well either: They lost the game. Nothing was good. He gets into bed and what does he say? “Oh, finally something good can happen today!”

Now, does that not describe the difference between men and women? Women need to be having fun to want to have sex and men want to have sex to have fun. So how are we going to deal with that? How are we going to take all of that and put it in some sort of context that we can use to make sense out of our lives? Because, after all, they are from Mars and we are from Venus.

The reality is that a lot of the science behind sexuality was designed around a very linear model: First, there’s desire, then there’s arousal, then we have orgasms, then we snuggle up. That does not work for women, does it? I don’t need to tell you that. For women, it’s much more circular. For us, sexuality is about intimacy. About relationships. About wanting to cuddle first and feel close to someone.

But it’s also about how we feel about ourselves. If we don’t feel like we’re attractive or sexy, then we can’t imagine how anyone else would feel that way about us. There are hundreds and hundreds of messages every day in the media that we all see that make us feel bad about ourselves. We see the airbrushed images, we see the people on television, we see all kinds of things that are not real to which we compare ourselves—and we don’t feel sexy.

So there’s a whole lot about female sexuality that’s involved in the environment that we live in, that’s involved in the quality of our lives. It has nothing to do with our hormones and everything to do with how we feel about ourselves.

What do you think the biggest sex organ in the body is? The brain. And 99-point-something-percent of our sexual function comes right here. I can write prescriptions for all the hormones in the world, but if my head is making a statement and playing a tape over and over that says I’m ugly, I’m unattractive, I’m fat, my breasts are saggy, my butt is saggy, I won’t feel attractive. So a lot of what our sexual function is all about is the story that we’re telling ourselves.

I want to backtrack and tell you a little about hormones—but not the hormones you thought I was going to talk about. You all thought I was going to talk about estrogen and testosterone, the hormones of desire and all those things. But that’s really not what I want to talk about, because these are brain hormones that we need to really understand. And the brain hormones are the hormones of lust and the hormones of love.

What happens when you first meet that truly attractive guy and it’s all looking good? You think he’s the one—this is it. And he can do no wrong. Nothing irritates you. You have all the energy in the world. You could meet him at two o’clock in the morning and it’s okay. And you can make love all night and still go to work the next day and feel energized. Right? That’s called PEA—phenylethylamine. It’s the hormone of lust.

The problem is: I don’t know how to make PEA and I don’t know how to get it into your brain. I’m sorry about that.

But this PEA hormone goes away after time. And the hormone of lust gives way to the hormones of attachment, and those are endorphin and oxytocin.

So, what changes is that we go from infatuation—from that phase in a relationship where nobody can do anything wrong and everything’s okay and you could not eat for days or you could eat a ton and it doesn’t matter ’cause you feel good all the time and you have more energy than you’ve ever had in your entire life—and what happens when that goes away? It goes away in about 6 months and the first thing that enters our heads is “Uh-oh, something’s going on and I’m not interested in him anymore” or “I’m not interested in the relationship anymore.”

That’s really not the case. What’s happening is that the relationship is maturing to a different phase of hormones, to a different style of working together. And that’s when we get into that circular model of female sexual function, which is all about intimacy.

Lots of people never get to that place, and go from relationship to relationship because they love that high. And I don’t blame them. You know that high is really exciting. But it’s not the stuff of long-term relationships. And when people have been together for many, many years—5 years, 6 years, 10 years, 12 years—the loss of that really exciting infatuation stage is something that people really miss a lot.

I’ll talk to you just a little bit about how you can get that feeling back. But what it is is not that something went wrong; it is that the relationship matured into something else. And, guess what? Relationships take work. The infatuation part, the part that’s purely physical, that’s a freebie. We all get that—that’s our species wanting to reproduce itself. But it has nothing to do with maintaining a long-term and satisfying sexual relationship. Nothing at all. So relationships take work and that means working on how women are in our culture and the things that we do to ourselves that get in the way of being truly sexual human beings.

What it is, is that life gets in the way. That day when the alarm clock doesn’t go off and the kids are at you and everything is going on, it’s playing its tape in your head and you’re thinking through all the things you need to do tomorrow and the next day and, oh by the way, he left the toilet seat up again and didn’t clean it up and you get angry. Now anger is an emotion that women are not supposed to feel, right? We’re not supposed to get angry, we’re supposed to be the fixers of everything. But the reality is that we do get angry and if we don’t express it, it festers. And that festering irritation at our partners and our families suppresses any chance of a good sex life. Because, if that’s what’s playing in your head, that’s not very attractive at all.

The challenge to us is to be able to manage life and still be sexual human beings. And that challenge is all about changing the tape that’s playing in our heads and setting a boundary about what our expectations are for ourselves—the boundary that says, “I really don’t need to be all things to all people at all times forever.” Because, if I try to be all things to all people at all times, I’ll never be there for myself. I’ll never learn what are the things that I can do to recapture what it is to be a really vibrant woman at any age in our culture.

So, I’m going to go through some of the things that I think we need to understand about sexuality to move us back to where we’d really like to be. I’m going to go through some of the physical things because I think they’re important, particularly for those of us who have matured beyond a certain hormonal stage in life.

When doctors talk about sexual dysfunction, the things that go wrong, they like to categorize things. So we have different categories of things. We talk about desire disorders, people who just don’t have any interest in sex. And for the most part, that comes from the tape we’re playing in our heads and it comes from how we’re approaching our relationship—how embroiled in the lives of our children and our work we’ve become, and how little time we devote to play. So sex is all about playing and pleasure.

But creating the time in our lives for play and pleasure is challenging in 2008. If you try to be all things to all people, there’s never ever any time left for you. If you don’t focus on you, then there’s no sexual desire. OK, so sexual desire is about play, it’s about creating some time in a relationship for focusing on the relationship. And what happens to us is that, usually, with the first child, everything gets focused on the child—and it has to be, for a while. You know our partners get irritated with us because we’re doing everything for the child, we sit and try to get our sex lives back and the first thing is—what? It hurts after you have a baby. And nobody told you it was going to hurt. And then your head says to you, “I’ll never be the same again.” And that tape starts to play over and over and we get further and further apart. So life gets in the way. Desire comes from that tape that we’re playing in our heads.

So that desire thing comes from the relationship. It comes from the need for intimacy. And it comes from our need to stop and play and create time in our lives to maintain our relationships because relationships take work. And if you don’t create that time to focus on the relationship, then that desire is not going to be there for women.

The model of sexuality is like this: Male sexuality is relatively straightforward—it’s pretty much a toggle switch. It’s on or it’s off. And it’s really easy to tell if it’s on or if it’s off!? Female sexuality is like the flight control panel of a 747 airliner, and if any flight controls don’t work, the airplane doesn’t take off. That is the reality.

Men have a wonderful feedback system to let them know whether they’re interested or they’re not. We don’t. It turns out that women can really disconnect that very well, right here at the neck. So we can be physically aroused and have absolutely no clue that we are. Absolutely no clue. And we can shut that off faster by one thought, and there have been some great studies to demonstrate that.

So I think the reality is we need to know what it is that we personally require in order to get interested in sex. For some of us, it’s romance and candles. For some, it’s videos or poetry. It’s a date night. It’s time for the relationship. It’s a vacation away without anyone else around. (How many of you have done that in the last year? Oh, there’s not one hand that went up. I’ll raise my hand. My husband and I take an annual honeymoon. It is absolutely inviolate that children can’t come. There can be no medical meetings. If he brings his computer I throw it off the balcony. Work is not allowed. We take a minimum of 7 days, sometimes 10, to go to a nice place that we both enjoy and that allows time for us—time for the relationship because that’s what I need and that’s in general what women need to make us feel good.)

So, we can get aroused but not know it. Our brains can turn off everything that we try to create, and so it’s important for you to understand female sexuality, what works for you, and what doesn’t. For some of us, it’s dressing in beautiful clothes. For some, it’s eating a great meal. For some it’s art; for others, music. It doesn’t matter what it is: What matters is that you begin to be aware of your own responses and what the things are that make you feel physically really good.

Now a lot of things do get in the way as we mature. We get physical illnesses, we have aches and pains. We have dryness. Headaches. Fatigue. And we need to optimize our general health to make our sexual health work.

Let me just tell you that there are a few things you can do, without drugs, that make a huge difference. Exercise makes a difference. I would be the wealthiest woman on earth if I could figure out some other way for you to get what exercise will do. It will increase blood flow to your brain. Your mental health will be much better. Your endorphins will rise and blood flow to your genitalia will increase.

Regular exercise significantly enhances sexual function and sexual response.

Maintain a good diet. When you feel crummy, you don’t feel sexy. And we’re going to feel crummy if we don’t eat well. And eating well means all those things that are the right things. It means lots of water—being well-hydrated. It means being careful with the caffeine so that you’re not jittery and feeling like you’re jumping off the walls. It means being careful to get the fruits and vegetables, the things that make you feel alive, that make your hair look better and your nails look better and your skin look better. Because when all those things look better, you feel better about yourself. Diet and exercise.

These are simple things, yet we don’t do them for ourselves because we’re spending our time taking care of everyone else. We’re not sitting down to have meals. We’re not creating the time in a schedule for regular exercise. But if I can do it, with my schedule, you can do it. What it means is putting it on the list of things to do—not at the bottom of the list but at the top, because we count. We are important. And as moms and grandmothers the best lesson we can give our daughters and our granddaughters is that women count. That we’re not supposed to be all things to all people at all times but we need to take care of ourselves. That is a key lesson that we need to learn for ourselves so that we can pass it on: Instead of envisioning yourself as being a bad mother or a bad wife for taking time for yourself, you’re actually empowering the next generation. And empowerment is what we really need to do to feel good about ourselves.

So what is it about? It’s about the brain. It’s about physical health to the best of our ability.

It’s true that, as we mature, there are more challenges. There are lots of drugs that people take that suppress sexual function. Be aware of what those are; talk with your physicians about any drug they want to put you on, and ask about their relationship to sexual function because, frequently, your doctors won’t tell you if you don’t ask. And they may not know—you may have to look it up yourself! For some conditions, such as high blood pressure and diabetes, there may be some drugs that will impair sexual function but others will not. You have to ask to be placed on a medication that will do well for you.

But the most important thing is to stay in touch with your brain. Stay in touch with that tape that you are playing over and over in your head. If that tape is empowering, and it says, “I am beautiful, I am sexy, I love my partner, I love this relationship,” that’s a whole different tape than the one that says, “He left the toilet seat up again and didn’t take out the trash and the lawn’s not done yet and the kids are this and that….” That tape in your head is an absolute turn-off.

What we need for great sex in our lives is time for play. Our priority is to take care of ourselves, to have an understanding of where sexuality really comes from. It comes from within us. It comes from the expression of being a whole woman, and that really comes from taking care of us. And it comes from an understanding that we play a tape in our head—and that we have a choice of which tape to play.