Hysterectomy is the most frequently performed major gynecologic surgery. Each of the current surgical techniques (vaginal, subtotal abdominal, and total abdominal hysterectomy) disrupts local nerves and changes pelvic anatomy. The effect on sexual function is unclear. Studies have reported beneficial effects and adverse effects on sexual wellbeing. Roovers and colleagues investigated sexual well-being after each type of hysterectomy in Dutch women who underwent surgery for a benign indication in 13 hospitals during 1999 and 2000.

In this prospective study, patients completed a screening questionnaire for sexual dysfunction as part of the preoperative assessment and the six-month follow-up visit. The 36-item questionnaire used a five-point Likert scale to assess the general perception of the patient's sexuality, frequency of sexual activity, and problems relating to arousal, lubrication, orgasm, or pelvic discomfort. The preoperative assessment included measurement of uterine size and screening for comorbid conditions such as diabetes, hypertension, hypothyroidism, pulmonary disease, and rheumatoid arthritis. Surgical data included the extent of uterine prolapse, estimated blood loss, duration of surgery, simultaneous surgical procedures, surgical complications, and length of hospital stay.

Six months after surgery, 352 of the 379 patients who had a male partner participated in the follow-up assessment. Of the 352 patients, 89 (25 percent) had undergone a vaginal hysterectomy, 76 (22 percent) had undergone a subtotal abdominal hysterectomy, and 145 (41 percent) had undergone an abdominal hysterectomy. Overall, 10 patients discontinued sexual activity after surgery; however, 17 of the 32 patients who had not been sexually active before surgery reported sexual activity at follow-up. No statistical difference was found in surgical technique among patients who remained sexually active or became sexually active. For each type of surgery, the percentage of respondents who were sexually active and the frequency of sexual intercourse were not significantly changed after surgery, and overall sexual satisfaction was significantly improved.

Bothersome sexual problems were still common and were reported by 43 percent of the patients who had undergone a vaginal hysterectomy, 41 percent of the patients who had undergone a subtotal abdominal hysterectomy, and 39 percent of the patients who had undergone a total abdominal hysterectomy. Problems with lubrication, arousal, and sensation were less common after vaginal surgery, but the differences did not reach statistical significance. After adjustment for multiple significant variables, the odds ratio for lubrication problems after abdominal rather than vaginal procedures was 1.6, and the odds ratio for arousal problems was 1.2.

The authors conclude that overall sexual well-being improves after hysterectomy, regardless of the surgical technique used. Specific sexual problems were more common before surgery, and new sexual problems were rare after surgery.

Source: Roovers J-P, et al. Hysterectomy and sexual wellbeing: prospective observational study of vaginal hysterectomy, subtotal abdominal hysterectomy, and total abdominal hysterectomy. BMJ October 4, 2003;327:774-8.

EDITOR'S NOTE: This is one of those "good news, bad news" reports. While the authors' data and conclusions show improvement in overall sexual function after hysterectomy, the level of symptomatology reported in the tables is horrifying. Before surgery, high percentages of women reported symptoms that interfered with sexual function--after surgery, more than 40 still had at least one bothersome sexual problem. We can only speculate about the implications for other aspects of their health, and the effect on their sexual partners, families, and others. Family physicians know how to assist patients in the most personal and sensitive aspects of human functioning, but do we remember to ask about sexual problems? Do we make it comfortable for women (and men) to disclose these concerns?

Anne D. Walling, M.D., is a professor of family and community medicine at the University of Kansas School of Medicine, Wichita, KS. She is also an associate editor of American Family Physician.

Concerns about staying sexual as you get older? Read about advanced age and sexual intimacy and how to remain sexually active in older age.

In many people's eyes, advanced age and sexual intimacy go together like oil and water. But sexuality can be an important part of any loving relationship, no matter how old you are. Below, experts in issues of elderly sexuality discuss popular misconceptions, as well as why -- and how - these misconceptions should change.

Are there benefits to being sexually active in older age, or is sex a health hazard for older people?

PATRICIA BLOOM, MD: Absolutely not. There are a lot of benefits to being sexually active, if one wants to be sexually active. Sexual activity is one of those stimulating kinds of activities that may promote brain function in elderly people. There's even some data to suggest that men who have many orgasms may live a longer life, although I suspect that what's really true is that men who are healthy enough to be very sexually active don't have underlying severe diseases, and therefore do live a longer life. I don't think that the sex causes you to live longer, but I think it's correlated with living longer.

When we talk about sex, are we talking about more than intercourse?

DAGMAR O'CONNOR, PhD: Hopefully we are. As they grow older, many couples stop having sex, because they only consider sex to be intercourse. They end up in my office saying, "Well, we can't have intercourse any more." And I find that they both masturbate separately and I ask them, "Well, why don't you bring that together and start having some sex life?" They say, "No, no, no, we can't do that. We must have intercourse." And I say, "How many more children are you planning to have? How important is this? It's a reproductive activity."

Touch is important, we know that we live longer when we have touch. Little babies die when they're not touched.

PATRICIA BLOOM, MD: One of the most serious losses of aging is the loss of physicality and physical intimacy. I think it's absolutely true that when you talk about sex in elderly people, you shouldn't focus just on intercourse, but on all of the other physical intimacies that people may derive great benefit from without necessarily engaging in intercourse. Some choose to have intercourse, but to think that that's the only aspect of sexuality in the elderly would be leaving out a lot of rich activity that some elderly, at least, find a great deal of pleasure in.

How can we, as a society, embrace sex in the elderly, and get rid of the taboo about Grandma and Grandpa having sex?

PATRICIA BLOOM, MD: When I mention sex in the elderly, my teenage son goes "Ewww!" There's still this thought that it's not something that's okay for elderly people to do. People get nervous thinking about it.

Does it become increasingly difficult to achieve a good erection for older men?

DAVID KAUFMAN, MD: There is some recent evidence that we have in our urologic literature that the more you use your erection, the better it will become. That has a lot to do with the oxygenation of the smooth muscle that is really the basis of an erection. The benefit is, the more sex you have, and the better blood flow that results from this sex, the better quality your erection's going to be.

That's why we've actually been using drugs. There are doctors who to be taken on a nightly basis without sex being involved in that night's activity, just to improve the blood flow to the penis during the night, improve oxygenation and, as a result, we have found that people's spontaneous erections are improved.

Is there any associated risk of heart disease and lung disease?

DAVID KAUFMAN, MD: Viagra (sildenafil citrate) has certainly gotten a bad rap by the lay press. I think the point that needs to be made is that people are not dying from Viagra (sildenafil citrate). They're having myocardial events because they're suddenly engaging in strenuous activities that they weren't engaging in because they were impotent.

If that same individual went outside and shoveled snow, he'd have the same heart attack he's having as a result of Viagra (sildenafil citrate). So members of the medical community need to be careful, and make sure that they're prescribing Viagra (sildenafil citrate) to people who are physically fit enough to participate in sexual relations.

Nitroglycerine compounds found in cardiac medications are absolutely and definitively contraindicated in somebody who's taking Viagra (sildenafil citrate). So we should not prescribe Viagra (sildenafil citrate) to anybody who either is taking, or might need to take, a nitroglycerine compound.

What about for older women who haven't had sexual intercourse in quite a while? Is it okay to resume sexual activity?

Yes, you can resume sexual activity, but it may take a little time and patience.

As women age, they experience several changes in their vaginal area. The vagina and vaginal opening often become smaller, especially when estrogen levels are low. It often takes longer for the vagina to swell and lubricate when you're sexually aroused. Together these can make intercourse painful. But there are steps you can take to alleviate the effects of these changes.

Longer foreplay helps stimulate natural lubrication. Often, the use of lubrication can be helpful. Several products such as K-Y jelly and Glide are available for this purpose. For some women, vaginal treatment with estrogen is the best way to increase natural lubrication.

If a woman hasn't had intercourse for a while, it will take time to stretch out the vagina so that it can accommodate a penis. Talk to your partner about what works best. Keep in mind, sex is more than intercourse. Touching and cuddling are an important part of sexual activity. Communication between partners is the best way to achieve sexual satisfaction.

How should a doctor address the sexual issues with older patients?

PATRICIA BLOOM, MD: It's very important that the doctor ask each and every patient if they're sexually active. If so, are there any problems? If they're not sexually active, is that a problem for them?

If we discover that a person is having a problem, then sometimes a door will open to a medical diagnosis of conditions that need to be treated in order to allow that person to be more sexually active. Sexual function is highly related to other medical conditions and needs to always be considered when you're treating other medical conditions.

What does the future look like for pharmaceuticals that offer people sexual help and hope?

DAVID KAUFMAN, MD: There is a whole sexual pipeline of pharmaceuticals that will be coming out. Viagra (sildenafil citrate) was really just the first of the lot. Within the next year, we're going to see coming out, dealing specifically with this issue.

If you have no memories of high school that make you blush, you are an exception to the rule. For most of us, adolescence is an intense and tumultuous time, and can leave us years later with the question, 'What happened back there?"

Dr. Jennifer Johnson wondered this herself. "I'm sure that I chose to work with teenagers for reasons that relate to my own adolescence, and probably some unresolved issues about that time. Adolescents are fascinating people. They're going through one of the most important and active developmental periods in their lives."

As the Chairperson of the Section on Adolescent Health of the American Academy of Pediatrics, and a practicing physician, Dr. Johnson knows more than most about American teenagers today. Below, Dr. Johnson shares some of what she's learned about teenage sexuality, risky behavior, and growing up.

When adults use the words 'teenager' and 'sexuality' together, they're usually describing a problem. But are there healthy ways for teenagers to express themselves sexually?

Sexuality is a very important part of who we are, and adolescents who have gone through puberty have the same hormones and the same hormonal drive as adults. And our society reinforces those drives. We do all kinds of direct and indirect things to encourage sexual intercourse and sexual behavior -- everything but talk about sexuality. So we're giving our kids a double message.

On the one hand, we're exposing them to people who have sex, for example, on TV, but on TV they don't talk about contraception and don't use condoms. We tell our teenagers, "No, you shouldn't do that," but we don't talk with them about how they might express their sexuality in a healthy way.

What are the current trends in teenage pregnancy?

The good news is that in the last five years or so, teen pregnancy rates in the United States have been declining. And there's a lot more condom use than there was in the mid-'80s, early '90s, which also helps protect teenagers from STDs.

But the United States has still got, by far, the highest teen pregnancy rate of any developed country in the world. The reason for that is not because our kids have sex at a younger age than in other cultures. It's because they're less likely to use contraception.

And because our pregnancy rate is so high, our abortion rate is also much higher than in other developed countries. About a third of adolescent girls who became pregnant have had abortions. And that's across the socioeconomic board, from poor kids to rich kids.

How well do kids understand sexual risks?

In general, early adolescents are not ready to understand the consequences of having sex. A lot of them don't really understand how babies are made, even in this day and age, and they have tons of misconceptions about pregnancy. There are still beliefs among teenagers that a girl can't get pregnant if she's on her period, or she can't get pregnant if it's her first time, or that pulling out is a reliable contraceptive method. There's a lot of misinformation.

Doesn't cognitive development have something to do with what teenagers understand about sex? The teenage brain is still growing...

Yes. Once they reach middle adolescence - 14 to 16 years old -- they can generally think abstractly, which makes it a lot easier for them to understand the implications of sex. Even though you can't see the egg and the sperm coming together, you can imagine how they might. And it appears that abstract thinking isn't really fully mature until people are around 17 to 19 years of age.

Are teenagers then inherently bigger risk takers than adults?

Yes and no. Adults do take risks, but often within a different context than adolescents. For example, the majority of pregnancies in adult American women, as in American teenagers, are unplanned. But adults are more likely to have completed their education, to be economically stable, and to have a stable relationship with the baby's father. Many experts believe that some degree of risk-taking is a normal part of adolescence. This is called "exploratory behavior," and it is part of finding out who you are, and what life is like.

But adolescents usually can't incorporate experience into risky situations. They don't have as much experience in solving problems -- they don't have the background. For instance, it's probably easier to avoid an accident when driving at night if you have hundreds of hours of daytime driving under your belt.

And when teenagers are in situations that are new and/or stressful, they tend to revert back from abstract thinking to concrete thinking.

So kids tend to steer their way through tricky situations using this less conceptual, or developed, thinking?

Yes, and that's one reason why a lot of prevention programs -- for sexual activity or pregnancy prevention or substance abuse prevention -- focus on teaching kids the skills that they need in new situations, sometimes even rehearsing the situations. They imagine scenarios they could find themselves in, and practice handling them.

Can you give an example?

So, "Okay, this guy that you've gone out with is pressuring you to have sex. What do you say?" And they actually practice. They have skill-building exercises. "How do you get home if things are uncomfortable, and you don't feel safe with this guy? What do you do?"

That goes back to my mother telling me to always take a dime in the heel of my shoe on a date so I'd be able to call home for a ride if I needed to.

The story's always the same.

Yes, it is. And you know, that was a wise thing that she did.

But getting back to taking risks, we do know that certain risk behaviors imply other risk behaviors, right?

Yes. Risk behaviors tend to cluster. If a kid is smoking cigarettes, now or within a short period of time that kid is more likely to become sexually active, more likely to drink alcohol, and probably more likely to experiment with other drugs, et cetera.

As a doctor, what sorts of information are you looking for from teenagers about their sex lives?

We're in a time-limited situation, so if the teenager has had sex, we usually focus on when they first had sex, and who their first partner was. If a girl had sex when she was 12, that raises red flags for me, because she's much more likely to have been sexually abused than a girl who didn't have sex until she was 16. And I ask how old the partner is. A girl whose partner is considerably older may feel pressure to have a baby. And of course there are many other ramifications if an adult is having sex with a minor.

I also want to know what kinds of protection they have used, among other things.

Do they share this information openly?

I find that kids are very willing to share information with me that can be critically important in their medical care as long as they know that confidentiality is going to be maintained and they can trust that confidence.

Do you find it difficult not be openly critical of teenagers when they tell you about their sexual experience?

I think in our society we are fairly judgmental, and as a physician, I feel I need to step back from that. There are sound medical reasons for delaying age at first sexual intercourse, limiting the number of sexual partners, and, of course, using protection against pregnancy and sexually transmitted infections.

But if I see a 13-year-old and talk with her about sexual intercourse, and she says, "I've decided I'm not going to have sex until I'm married," I reinforce to her the value of holding off on having intercourse. And if a kid is 15 or 16 and having sexual intercourse, I don't think it is helpful to say, "Don't do it anymore," but I'll try to make sure that she or he is adequately protected from pregnancy and STDs. And I talk with them about these as potential consequences of sex. But I try to do it in a nonjudgmental way.

Doctors who care for teenagers should encourage them to behave in ways that are physically and emotionally healthy and respectful of themselves and others. I don't think that telling a sexually active teenager that what he or she is doing is "wrong," is helpful or productive. On the other hand, this doesn't mean I can't ask a 15-year-old girl who is thinking about having sexual intercourse whether she would like my opinion about it.

What I tell our residents is that you need to learn how to provide medical service to these kids, and in your practice, if you feel that you can't provide nonjudgmental care for them, then you should refer them to another physician. I think it's critical that doctors who are providing care for teenagers be nonjudgmental. It's just an absolute prerequisite.

The idea of anxiety ruining relationships may seem a bit dramatic, but sadly, it can be true that anxiety ruins relationships. Anxiety is overpowering. When it intrudes on someone, it bulldozes itself into their relationships, too. It affects someone’s thoughts, emotions, and actions, clouding perceptions and leading to misinterpretations and misery. When this happens in the context of a relationship, it can
cause an incredible amount of stress and misunderstandings. Anxiety ruins relationships when worries, what-ifs, emotions, thoughts, and behaviors crowd out the positive that once existed between two people.

Is “ruin” the right term, though? Are relationships really destroyed by anxiety? Let’s take a look.

Can Anxiety Ruin Relationships?

When someone lives with anxiety, their life becomes increasingly restricted so that negative, anxious thoughts and beliefs become paramount. As the focus of the relationship, anxiety wedges itself between the partners, blocking their view of each other. When people lose sight of each other because of anxious ideas and behaviors, anxiety ruins the relationship.

Anxiety has been shown to increase relationship problems. People living with generalized anxiety disorder (GAD), for example, are more prone than those without GAD to experience relationship problems, including divorce (Cuncic, 2018). According to the Anxiety and Depression Association of America (n.d.), people with GAD are twice as likely as those without anxiety to have at least one significant relationship problem and are three times more likely to avoid intimacy.

Intimacy is a vital component of healthy relationships. Avoiding it due to anxiety (such as fear of inadvertently displeasing their partner), can be a deal-breaker. It’s not just GAD that interferes in relationships and causes their demise. Any anxiety disorder can do this as can anxiety that doesn’t meet the diagnostic criteria for a disorder. Essentially, any type of anxiety can ruin relationships.

Anxiety in a relationship is incredibly stressful. Worries, what-ifs, fears, thoughts emotions, and behaviors cause angst, both to the person with anxiety and their partner. Stress becomes a theme for the relationship. Barriers form between partners, which create greater and greater distance. All too often, this unhealthy situation leads to the demise of the relationship. In answer to the above question, then, yes—anxiety can ruin relationships.

By looking more closely at why anxiety ruins relationships, we can gain knowledge that can be used to prevent relationships from breaking apart because of anxiety.

Why Anxiety Ruins Relationships

Anxiety ruins relationships because it intrudes. It creates negative thought patterns and beliefs, and it makes them larger than life (as in bigger and more believable than reality). These issues erode feelings of connection and the ability to trust. Anxiety becomes an obstacle as it commands the attention of both partners. Rather than being fully present with each other, both the person with anxiety and their partner place too much attention on the anxiety. This, in turn, leads to feelings of disconnection, separation, and abandonment.

Anxiety is a critical voice that shouts not “sweet nothings” but “mean somethings.” A big part of any type of anxiety is self-doubt that talks over the rational thoughts and words of both partners. Anxious thoughts and beliefs held by the partner with anxiety says such things as:

• You’re incompetent
• You don’t deserve your partner’s love
• You aren’t a good partner
• Your partner is going to leave you
• You should protect your partner so nothing bad happens to them

If anxious thoughts would remain mere thoughts, they’d be annoying but probably wouldn’t ruin relationships. Anxiety never remains as thoughts, however. Instead, they bleed into emotions and dictate behaviors. Certain types of anxious behaviors, stemming from both thoughts and emotions, are common in relationships:

• Clinginess, overdependence, attachment, and an extreme need for closeness, reassurance
• Jealousy, possessiveness, suspiciousness
• Withdrawal, retreat, and isolation
• Cold, rejecting, punishing, shunning
• Avoidance of open, honest communication

Anxiety drives these behaviors, but it’s not just the person with anxiety who uses them. Anxiety ruins relationships because relationships can’t sustain themselves with these barriers to closeness, fun, and intimacy.

Awareness of how anxiety ruins relationships can give couples a starting point in reconnecting. While
anxiety can ruin relationships, it doesn’t have to obliterate them, crushing them beyond repair.

article references

Dr. Frank Lawlis, author of The ADD Answer, offers nutritional advice for parents whose children are diagnosed with ADHD (Attention Deficit Hyperactivity Disorder).

A healthy diet is important for all children and adults but it is even more important for those who suffer attention deficit disorder, according to Dr. Frank Lawlis, author of The ADD Answer: How to Help Your Child Now. Eating the right foods maximizes concentration, learning capacity and self-control, and poor nutrition choices can exacerbate symptoms of ADD or cause medical problems.

In his book, Dr. Lawlis offers the following audit to help focus on what dietary elements might be contributing to your child's symptoms.

Following are some of the foods that have been investigated and found to have negative impacts on children's health.

• Artificial colors and preservatives
• Processed milk and milk products
• Wheat products, but only breads and cereals that are not whole grain.
• Sugar
• Oranges and grapefruits
• Eggs
• MSG

The great news is that substituting healthier foods can immediately reduce ADD symptoms in many cases. There are a number of excellent studies that have demonstrated 50 to 70 percent resolution of hyperactive behavior and increased concentration spans with alternative menus.

The Hero's Diet Plan

The following is a nutritional plan for children with ADD created by Dr. Lawlis. It doesn't require high-priced foods or supplements. The only one requirement for this plan to work is that the entire family needs to go on it. It is hard enough to change a child's food habits without having a brother or sister eating his favorite fast foods in front of him. It is also important to show family support and solidarity.

Our bodies were not designed to handle processed and greasy foods. Put the fryer and microwave in storage. Eat most foods in their raw and natural states. Those that need to be cooked should be boiled or grilled over a low flame to reach at least water's boiling point (212 º F). To get your children to eat raw vegetables and other healthy raw foods like raisins, put a little peanut butter or honey on them.

The most difficult thing you may ever have to do is tell a loved one you have HIV. Disclosing your HIV status is difficult but sometimes necessary. This "how-to" will help you disclose your HIV status with the least amount of stress.

Difficulty: Hard

Time Required: As much as you need

Here's How:

1. Know why you want to tell the people you are telling. What do you want from them?

2. Anticipate their reaction. What's the best you can hope for? What's the worst you will have to deal with?

3. Learn as much as you can about HIV.

4. Have articles or printed material to give to the person to help them understand.

5. Get support. Talk it over with someone you trust and come up with a plan.

6. Accept the reaction. You can't control the fears and feelings of others.

7. Be patient. It may take some time for those you tell to process the information.

Tips:

1. Past sexual partners should be told you are HIV positive so they can be tested.

2. Local health departments or your health care provider can assist with partner notification and can do it anonymously.

3. Health care providers can give you more appropriate medical care if they know you complete medical history. Disclosing your status to your health care team is important.

4. Be sure you are ready to tell and are able to handle the reactions you may receive.

Read:How to tell others, your employer, your child's school that you are HIV positive and some personal stories

Given that women now live approximately one-third of their lives after menopause and continue to be sexually active beyond the cessation of reproductive functioning, the sexual history should now be a routine component of the annual clinical visit of the woman in midlife and beyond. ⁽¹⁾ Kingsberg suggests that pre- and postsurgical visits (for uterine prolapse, hysterectomy, oophorectomy, mastectomy, etc.), as well as those related to menopause, chronic illnesses, and depression, also lend themselves to the inclusion of assessment for sexual disorders. ⁽²⁾

Contraception and Risk of Unintended Pregnancy and STIs in Perimenopausal and Menopausal Women

Women over the age of 40 have the second highest proportion of unintended pregnancies, so the need for effective contraception continues into midlife until menopause.³ No contraceptive method is contraindicated by age, and certain methods, such as oral contraceptives (OCs) and other hormonal methods, may stabilize hormone levels and ease the transition through menopause.^3,4 The decision about which method to use should be guided by patient preference, lifestyle, behaviors (e.g., cigarette smoking), and medical history.^3,4 Safe-sex practices should be discussed with all patients regardless of their age or sexual orientation.

Starter Questions

Kingsberg suggests that a general sexual assessment needn't take an inordinate amount of time.⁽²⁾ Begin the assessment by asking the patient the following questions to convey your willingness to discuss sexual issues:

• Are you currently involved in a sexual relationship?
• Do you have sex with men, women, or both?
• Are you or your partner having any sexual difficulties or concerns at this time, or do you have any questions or concerns about sex?

More extensive questioning can include the following:

• Are you satisfied with your current sexual relations?
• Do you have any sexual concerns you would like to discuss?

If a patient responds with answers suggesting she has concerns and wants to discuss them, you might then proceed as follows:

• "Tell me about your sexual history-your first sexual experiences, masturbation, how many partners you've had, any sexually transmitted infections or past sexual problems you've had, and any past sexual abuse or trauma."
• "How often do you engage in sexual activity?"
• What kinds of sexual activities do you engage in?
  • Depending on the sexual orientation of the patient, ask about the specific forms of sex, including penis in mouth, vagina, or rectum; mouth on vulva.
  • If the woman is a lesbian, ask if she has ever had penetrative sex with a man, to assess her risk of cervical cancer and sexually transmitted infections.
• "Do you have difficulty with desire, arousal, or orgasm?"
  • If the woman is peri- or postmenopausal, preface these questions with information that many women often experience vaginal dryness and changes in sexual desire around the time of menopause.

Along with sexual activity questions, a standard menstrual and obstetric history should be obtained, inquiring about the age of onset of menses, last menstrual period, characteristics of menstrual periods, problems associated with menses in the past, pregnancy-related problems, and perimenopausal/menopausal symptoms. ⁽²⁾

Physical Examination

A comprehensive physical examination should be conducted to detect potential contributors to or causes of sexual problems. This examination, which should be conducted with close monitoring and input from the patient to isolate potentially painful areas, should also be used to educate the patient about her reproductive anatomy and sexual functioning.⁽⁵⁾

Click here to see table 9

Diagnosis

Basson has developed an algorithm (click here to see Figure 4) to help providers establish a diagnosis of sexual problems in women. This algorithm incorporates both physical and psychosocial elements of sexual functioning (such as whether a woman is distressed about a change in her sexual functioning).^(2,6)

References:

1. Kingsberg SA. The impact of aging on sexual function in women and their partners. Arch Sex Behav 2002;31(5):431-437.
2. Kingsberg S. Just ask! Talking to patients about sexual function. Sexuality, Reproduction & Menopause 2004;2(4):199-203.
3. Stewart F. Menopause. In: Hatcher RA, Trussell J, Stewart F, et al., eds. Contraceptive Technology. 17th ed. New York: Ardent Media; 1988, pp 78-79.
4. Williams JK. Contraceptive needs of the perimenopausal woman. Obstet Gynecol Clin North Am 2002;29:575-588.
5. Phillips NA. Female sexual dysfunction: evaluation and treatment. Am Fam Physician 2000;62:127-136, 141-142.
6. Basson R. Sexuality and sexual disorders. Clinical Updates in Women's Healthcare 2003:1:1-84.

ADHD can affect a child's success in school. ADHD symptoms, inattention, impulsiveness and hyperactivity, get in the way of learning. Discover how parents can help their ADHD child with school.

You are your child's best advocate. To be a good advocate for your child, learn as much as you can about ADHD and how it affects your child at home, in school, and in social situations.

If your child has shown symptoms of ADHD from an early age and has been evaluated, diagnosed, and treated with either behavior modification or medication or a combination of both, when your child enters the school system, let his or her teachers know. They will be better prepared to help the child come into this new world away from home.

If your child enters school and experiences difficulties that lead you to suspect that he or she has ADHD, you can either seek the services of an outside professional or you can ask the local school district to conduct an evaluation. Some parents prefer to go to a professional of their own choice. But it is the school's obligation to evaluate children that they suspect have ADHD or some other disability that is affecting not only their academic work but their interactions with classmates and teachers.

If you feel that your child has ADHD and isn't learning in school as he or she should, you should find out just who in the school system you should contact. Your child's teacher should be able to help you with this information. Then you can request—in writing—that the school system evaluate your child. The letter should include the date, your and your child's names, and the reason for requesting an evaluation. Keep a copy of the letter in your own files.

Until the last few years, many school systems were reluctant to evaluate a child with ADHD. But recent laws have made clear the school's obligation to the child suspected of having ADHD that is affecting adversely his or her performance in school. If the school persists in refusing to evaluate your child, you can either get a private evaluation or enlist some help in negotiating with the school. Help is often as close as a local parent group. Each state has a Parent Training and Information (PTI) center as well as a Protection and Advocacy (P&A) agency.

Once your child has been diagnosed with ADHD and qualifies for special education services, the school, working with you, must assess the child's strengths and weaknesses and design an Individualized Educational Program (IEP). You should be able periodically to review and approve your child's IEP. Each school year brings a new teacher and new schoolwork, a transition that can be quite difficult for the child with ADHD. Your child needs lots of support and encouragement at this time.

Never forget the cardinal rule—you are your child's best advocate.

Source: Excerpted from the National Institute of Mental Health ADHD publication, June 2006.

Family dynamics may be upset when there's a child with ADHD in the house. Here are some tools to help ADHD children and their families.

Medication can help the ADHD child in everyday life. He or she may be better able to control some of the behavior problems that have led to trouble with parents and siblings. But it takes time to undo the frustration, blame, and anger that may have gone on for so long. Both parents and children may need special help to develop techniques for managing the patterns of behavior.

In such cases, mental health professionals can counsel the child and the family, helping them to develop new skills, attitudes, and ways of relating to each other. In individual counseling, the therapist helps children with ADHD learn to feel better about themselves. The therapist can also help them to identify and build on their strengths, cope with daily problems, and control their attention and aggression. Sometimes only the child with ADHD needs counseling support. But in many cases, because the problem affects the family as a whole, the entire family may need help. The therapist assists the family in finding better ways to handle disruptive behaviors and promote change. If the child is young, most of the therapist's work is with the parents, teaching them techniques for coping with and improving their child's behavior.

Tools to help ADHD Children and their Families

Several intervention approaches are available. Knowing something about the various types of interventions makes it easier for families to choose a therapist that is right for their needs.

Psychotherapy works to help people with ADHD to like and accept themselves despite their disorder. It does not address the symptoms or underlying causes of the disorder. In psychotherapy, patients talk with the therapist about upsetting thoughts and feelings, explore self-defeating patterns of behavior, and learn alternative ways to handle their emotions. As they talk, the therapist tries to help them understand how they can change or better cope with their disorder.

Behavioral therapy (BT) helps people develop more effective ways to work on immediate issues. Rather than helping the child understand his or her feelings and actions, it helps directly in changing their thinking and coping and thus may lead to changes in behavior. The support might be practical assistance, like help in organizing tasks or schoolwork or dealing with emotionally charged events. Or the support might be in self-monitoring one's own behavior and giving self-praise or rewards for acting in a desired way such as controlling anger or thinking before acting.

Social skills training can also help children with ADHD learn new behaviors. In social skills training, the therapist discusses and models appropriate behaviors important in developing and maintaining social relationships, like waiting for a turn, sharing toys, asking for help, or responding to teasing, then gives children a chance to practice. For example, a child might learn to "read" other people's facial expression and tone of voice in order to respond appropriately. Social skills training helps the child to develop better ways to play and work with other children.

ADHD Support groups help parents connect with other people who have similar problems and concerns with their ADHD children. Members of support groups often meet on a regular basis (such as monthly) to hear lectures from experts on ADHD, share frustrations and successes, and obtain referrals to qualified specialists and information about what works. There is strength in numbers, and sharing experiences with others who have similar problems helps people know that they aren't alone. National organizations are listed at the end of this document.

Parenting skills training, offered by therapists or in special classes, gives parents tools and techniques for managing their child's behavior. One such technique is the use of token or point systems for immediately rewarding good behavior or work. Another is the use of "time-out" or isolation to a chair or bedroom when the child becomes too unruly or out of control. During time-outs, the child is removed from the agitating situation and sits alone quietly for a short time to calm down. Parents may also be taught to give the child "quality time" each day, in which they share a pleasurable or relaxing activity. During this time together, the parent looks for opportunities to notice and point out what the child does well, and praise his or her strengths and abilities.

This system of rewards and penalties can be an effective way to modify a child's behavior. The parents (or teacher) identify a few desirable behaviors that they want to encourage in the child—such as asking for a toy instead of grabbing it, or completing a simple task. The child is told exactly what is expected in order to earn the reward. The child receives the reward when he performs the desired behavior and a mild penalty when he doesn't. A reward can be small, perhaps a token that can be exchanged for special privileges, but it should be something the child wants and is eager to earn. The penalty might be the removal of a token or a brief time-out. Make an effort to find your child being good. The goal, over time, is to help children learn to control their own behavior and to choose the more desired behavior. The technique works well with all children, although children with ADHD may need more frequent rewards.

Concentrate on helping your ADHD child succeed

In addition, parents may learn to structure situations in ways that will allow their child to succeed. This may include allowing only one or two playmates at a time so that their child doesn't get overstimulated. Or if their child has trouble completing tasks, they may learn to help the child divide a large task into small steps, then praise the child as each step is completed. Regardless of the specific technique parents may use to modify their child's behavior, some general principles appear to be useful for most children with ADHD. These include providing more frequent and immediate feedback (including rewards and punishment), setting up more structure in advance of potential problem situations, and providing greater supervision and encouragement to children with ADHD in relatively unrewarding or tedious situations.

Parents may also learn to use stress management methods, such as meditation, relaxation techniques, and exercise, to increase their own tolerance for frustration so that they can respond more calmly to their child's behavior.

Children with ADHD may need help in organizing. Therefore:

• Schedule. Have the same routine every day, from wake-up time to bedtime. The schedule should include homework time and playtime (including outdoor recreation and indoor activities such as computer games). Have the schedule on the refrigerator or bulletin board in the kitchen. If a schedule change must be made, make it as far in advance as possible.

• Organize needed everyday items. Have a place for everything and keep everything in its place. This includes clothing, backpacks, and school supplies.

• Use homework and notebook organizers. Stress the importance of writing down assignments and bringing home needed books.

Children with ADHD need consistent rules that they can understand and follow. If rules are followed, give small rewards. Children with ADHD often receive, and expect, criticism. Look for good behavior and praise it.

Sources:

• Attention Deficit Hyperactivity Disorder, a publication of NIMH, June 2006.

Almost without exception, ADHD makes people feel like a failure. Symptoms of adult ADHD, such as inability to be still, to focus, to pay attention, to plan, and to organize, get in the way of the tasks of life. This can be highly frustrating and can leave someone with ADHD feeling like they just don’t measure up to everyone else.

The nature of ADHD can create what is sometimes referred to as a cycle of failure (Selikowitz, 2009). The cycle of failure in adults with ADHD looks like this:

• Feelings of failure and inadequacy
• Desire to avoid tough situations and back away from challenges
• Diminished achievements due to lack of effort
• Feelings of worthlessness, small accomplishments feel meaningless
• Strong sense of incompetence
• Feelings of failure and inadequacy
• Continuation of the cycle

This cycle of failure can be a trap. You, however, are the one who holds the key to that trap. Your ADHD doesn’t have to keep you in its snare. Here are five tips to help you use your key to unlock the trap so you can break free from the cycle of adult ADHD and feeling like a failure.

5 Ways to Handle Adult ADHD and Feeling Like a Failure

1. Empower yourself with action. Actions are more powerful than thoughts, words, and feelings. Consider exactly what’s on your mind. Of your feelings of failure, what is bothering you the most right now? What small actions can you take, today and every day, to make the changes you want? Avoidance is part of the cycle of failure, and action is part of the cycle of success (Finding the Best Job for Your ADHD Brain).
2. Explore your interests. Find flow. You are so much more than your ADHD, but ADHD doesn’t give you a chance to figure that out. Rather than ruminating about things you can’t do, turn your attention to what you’d like to do. Start out by finding things that you want to do just for fun, for hobbies. That way, you face no pressure to perform. Finding something you love to do and simply doing it is a great way to grow past that sense of failure.
3. Develop a sense of purpose and belonging. People with ADHD often feel isolated. Learning social skills will help you interact positively with people and feel a sense of belonging. Belonging to a group brings acceptance, camaraderie, mutual support, and fun, all of which boost success and banish that experience of adult ADHD and feeling like a failure (ADHD and Friendships: How to Make and Keep Friends).
   Create a sense of purpose while finding others to connect with. What are your passions? Do you want to find an adult ADHD support group? Volunteer in schools? Help people repair bicycles? The sky’s the limit. Helping others by doing something you love and are good at keeps you from feeling like a failure.
4. Avoid comparing yourself to others by finding and appreciating your strengths. Regardless of whether someone has ADHD or not, making comparisons to others will bring on a sense of failure nearly every time. Making comparisons isn’t a healthy thing to do, yet people with ADHD do it all the time. Seeing only your weaknesses and comparing them only to someone else’s strengths creates a strong sense of inadequacy. Instead, turn your attention inward. Identify those traits that you’d like to improve (everyone has them), and also identify traits that you like about yourself. What are your strengths? What are you good at? How do you already use them in your life, and how do you want to use them even more? This balanced view of yourself helps you see and believe that you’re not a failure. Find guidance for identifying and using your character strengths on the VIA Institute on Character website.
5. Accept imperfections and decrease perfectionism. People with ADHD tend to be incredibly hard on themselves, and often on others, too. As you work through the belief that you’re a failure, it’s important to know that this isn’t a black-or-white, all-or-nothing concept. Being imperfect doesn’t mean you’re a failure, just like being successful doesn’t require perfection.
   Part of doing this is learning to accept praise from others, something that’s hard for people with ADHD to do. But when you can listen to what someone is telling you and accept the praise you’re being given, you begin to learn that you are worthy, you are good enough, without having to be perfect.

If you have ADHD and find yourself feeling like a failure, use one or more (they all work together) of these five ways to believe in yourself.