This is a case study that couples in midlife should read. There can never be too much communication in the bedroom.
Sam and Linda got married in a fever. They were old enough to know what they liked and young enough to have sex every day, sometimes twice. Both had been married before and their other marriages had been unsatisfying sexually. They were well matched this time and valued their sexual life.
After the birth of their first child, Linda retired from the workplace and devoted herself to her husband, her children and her home. This traditional life worked well for both Sam and Linda. Sam’s father had died when he was young. He needed to be a devoted father and the wage earner in the family. It helped him heal the loss from his childhood. Linda’s parents had divorced when she was in seventh grade and her mother had worked at two jobs. Linda wanted her children and family to have the security and comfort that a full-time at-home mother could provide.
Their daughter was born two years later. Sam and Linda lived carefully and were able to avoid financial pressure. They never bought a replacement car until the old one died.
Vacations were modest and always child-centered. Sex continued to be a source of joy to this couple, and they always found time for each other’s intimate needs.
Since Sam’s father had died young of a heart attack, Sam had always exercised, watched his diet, and was fit and thin. He was surprised when his blood pressure was elevated on a routine physical when he was 50. It didn’t seem fair. He had done everything right.
After a series of diagnostic evaluations, the doctor recommended that Sam begin a medicine to lower the blood pressure and another drug to lower his cholesterol.
Sam complied with the medical treatment. But he became slightly depressed and angry about his blood pressure problem and the need to take drugs every day. His mood didn’t just affect his libido: it also had an impact on his relationship with Linda. Over time, he accepted his diagnosis and became accustomed to taking pills every day.
The doctor, who was pleased with Sam’s response to the medication, was understanding when Sam brought up the subject of his emotional response to his diagnosis and treatment. He explained that it was normal for a patient to be angry and disappointed when given news that they have a life long medical problem. Sam was reassured, and much more optimistic after this visit.
As for Linda, she believed in preventive care and maintenance of her vaginal health. She was at the end of her menopausal transition, and had chosen to use vaginal estrogen after the onset of vaginal dryness and discomfort with sex in spite of over-the-counter vaginal lubricants. She felt that her choice was reasonable after the discussion of risks and benefits with her gynecologist She found that the vaginal estrogen was effective and easy to use. Linda had a frank talk with her gynecologist about the importance of sex in her marriage and they agreed that she would only use the vaginal estrogen while she was having sexual intercourse.
Sam had no interest in sex for the first few months after his diagnosis of high blood pressure. He was moody and short-tempered, and he gave Linda no explanation for his change in behavior and temperament.
Linda was concerned at first, then angry that Sam no longer wanted to have sex. She tried to introduce the subject but Sam was unwilling to talk about sex. Linda knew that she was a good looking woman, fit and fun to be around. She felt that Sam must be having an affair and she became distant as well
Sam gradually became more optimistic and began to work on his relationship with Linda.
She was unconvinced that he had been faithful but was willing to resume their sexual life.
The first time that they had sex after several months of celibacy, Sam found that he was unable to sustain an erection. This had never happened to him before. He was ashamed and confused. He felt that Linda was rejecting him and that this was a reason for his erectile dysfunction. Linda was now convinced that he was having an affair and that he no longer found her sexually attractive. They tried to joke about it and postponed any serious talk.
The serious talk never materialized. They tried again on two more occasions to have sex, but Sam could neither sustain an erection or ejaculate. They tried to treat each other well in all other areas of their relationship, but trust, shame and loss of intimacy took its toll. Linda chose to stop using the vaginal estrogen and quietly put aside her libido. She missed their intimate life but they gradually became good friends again and became comfortable with hugs and quick kisses.
Sam saw his doctor for a follow-up visit and the doctor asked Sam if he had had any sexual side effects from the medication. Sam was amazed to learn that both high blood pressure and the drugs he was taking could affect erectile function. The doctor explained that performance anxiety could be an added factor and asked Sam if he were interested in trying Viagra. He reassured Sam that it was a safe drug for him to take and carefully discussed how to use the medication. Sam was elated: There was a reason for this shameful problem, and there was a medicine to fix it! Sam bought his little pills and planned a surprise for Linda.
That night he took his first magic tablet, and was unbelievably amorous. Linda was surprised and initially delighted. Then she found that intercourse, in spite of vaginal lubricants, was painful. She was afraid to tell Sam since he was so pleased with the return of his masculine performance so she tried to relax and suffered through a very long period of intercourse that became increasingly painful for her. Sam had never sustained an erection this long before. She couldn’t understand it. Finally, it was over. Sam then decided to tell her about the surprise. Linda was furious. She felt that Sam had become more and more duplicitous.
Linda saw her gynecologist several days later when the genital discomfort worsened. She was told that her genital tissue was thin and dry and that she had suffered abrasions and tiny tears in the genital mucosa from this first episode of intercourse after a long period of celibacy and months of no vaginal estrogen. The gynecologist gave Linda Vitamin D and then vaginal estrogen and explained to Linda that it would take about 6 weeks for genital tissue to become healthy and comfortable enough for intercourse. The gynecologist explained to Linda that she should have a serious conversation with Sam before they renewed their sex life.
Linda and Sam chose to talk to a therapist a few times to restore trust and find a comfortable way to reinvent their sex life. They learned that sexual intimacy actually requires communication of the verbal sort. They now refer to this period in their lives as the time of the Vagina Dialogues.
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