Since menopause, Julie has been losing sleep and gaining weight. Tired, cranky and unhappy with herself, sex was the last thing on her mind. But it seemed to Julie, sex was always first and foremost on her husband's mind. The tension between the couple had gotten so bad that they dreaded being alone together.

About a year ago, Alex, a 45 years old accountant, started having difficulty getting an erection. Alex was so embarrassed by his problem that he no longer initiated sex with his wife, Kathy, and was unreceptive to her advances. Kathy became so cold and distant, that Alex began to feel that she was rejecting him. The couple had not had sex--or even a meaningful conversation—for nine months, and the lack of intimacy was taking its toll on their relationship.

These stories are typical of those we hear from the men and women we see at the Jefferson-Myrna Brind Center of Integrative Medicine at Thomas Jefferson University and Hospital. Our patients seek our help because their lives are not the way they used to be…or the way they want them to be.

Until recently, many couples like these would have dismissed their sex problems with, "What do you expect? We're middle aged." The new generations of midlife couples expect a great deal more.

They expect to have great sex, great health and a great life well into their later decades.

Dr. Monti, the Director of the Center, is a physician with a specialty in psychiatry and couples' counseling. Dr. Bazzan is an internist/geriatrician and a specialist in aging. Dr. Bazzan is our hormone specialist and heads the Andropause and Menopause Program at the Center. (Andropause, also known as "male menopause" refers to the decline of testosterone and other changes that occur in midlife men.) We are the only geriatrician-psychiatrist team we know of to head a university based program for male and female menopause. We sometimes call ourselves "anti-geriatricians" because we aim to keep our patients as youthful as possible, for as long as possible. Our real interest is in helping our patients avoid the pitfalls of aging. We both had traditional medical school experiences.

We wrote this book to make a difference. For years we have been helping men and women get a better grip on their health, and their relationships, and thereby improve their quality of life.

Our goal is nothing less than a complete life makeover. We want you to have a great life, and we're going to show you how. Within the pages of book, you will find the tools you need to get your health, your life and your relationship back on track.

HER
He's got the libido of an 18 year old, and I don't. Sometimes I feel dead below the waist, I try to get turned on, but nothing happens. And when we have sex it can hurt.

HIM
She does not want to have sex as much as I do. But even when we do, she's not really enjoying it. I love her. I want things to be better.

In the not too distant past, menopause coincided with what we would call "old age." At the turn of last century, average woman didn't make it past 50. Today, the average woman lives many decades beyond menopause and wants to live them in a healthy, vital body with a sharp, active mind. But that's not what nature intended for us.

We may not like to think of ourselves solely in terms of our reproductive role, but nature views us differently. Our bodies are designed to maintain optimal health throughout the child bearing years. Once we move out of our prime reproductive years, our body systems begin to wear down one by one. This is true for both men and women, but since women are the ones who the bear the children, they are hit the hardest.

The average age of menopause for women in the U.S. is 54, but hormone production begins to fall off long before, typically causing menstrual irregularities and other perimenopausal symptoms. In fact, many of the symptoms we associate with menopause, such as insomnia, hot flashes and irritability, often begin during perimenopause.

For women, the decline in reproductive ability begins in their mid to late 30s and accelerates throughout the 40s. That's why for every year over 30, it becomes increasingly difficult to get pregnant. Menopause is defined as the cessation of the menstrual cycle which is caused by the depletion of living, viable eggs inside the ovaries. If you're a woman over 50 and you haven't had a period within one year, you are officially considered to be menopausal.

A girl is born with roughly a half a million immature eggs or follicles in her ovaries; the monthly menstrual cycle revolves around preparing one of those eggs for a potential pregnancy. The cycle is usually divided into two parts—the estrogen phase and the progesterone phase. In the first part of the menstrual cycle (the estrogen phase), the pituitary releases FSH (follicle stimulating hormone) which prepares one of the eggs for fertilization. The developing egg releases high amounts of estrogen, which brings about a drop in FSH production.

Women make 3 types of estrogens: estradiol, estrone and estriol. Estradiol is the primary and most potent estrogen. It is responsible for normal menstrual flow, bone mineral and density, as well as mood, sex drive, proper function of the heart and blood vessels, skin elasticity and brain and thyroid function. In other words, the influence of estrogen extends far beyond the reproductive system.

At around day 14, or mid cycle (the progesterone phase), there is a surge of luteinizing hormone (LH), which causes the egg to rupture, signaling to the ovaries to release the mature egg (now called the corpus luteum) into the fallopian tubes where it travels to the uterus. The corpus luteum begins producing progesterone along with estrogen. The uterine lining thickens to support a possible pregnancy. If the egg is not fertilized, hormone levels drop and the uterine lining is shed during next menstrual period.

The egg is the "brain" that regulates the balance of hormones during the menstrual cycle. And once the supply of eggs dries up, hormone production sharply declines, creating an imbalance. The pituitary gland still produce FSH in a last ditch effort to stimulate ovulation, but to no avail. There are hormone fluctuations that can make women feel miserable, triggering hot flashes and night sweats. The higher the FSH, the harder the ovaries are working to produce estrogen, a sign of estrogen deficiency.

Progesterone is the first hormone to go, falling steeply during perimenopause. By the time menopause is completed, a woman can lose up to 90% of this hormone. Progesterone can have a big impact on a woman's quality of life. As women lose progesterone, they often experience problems sleeping and may feel anxious, more irritable or even depressed.

Estrogen levels also begin to drop, albeit more slowly than progesterone, and by the time a woman is menopausal, she has lost between 40 to 60 percent of her estrogen.

Although not involved in the menstrual cycle, women lose another important hormone that has a profound impact on their lives. The production of testosterone drops by up to 90% in women. Similar to progesterone, testosterone is important for mood, but it's also important for sex drive, body composition, bone density and maintaining an overall feeling of well being. For some women, the loss of testosterone is as bad, if not worse, than the loss in estrogen.

It's important to remember that menopause is a process that plays out over time. For some women, the hormonal ups and downs can last a decade or longer, punctuated by difficult menstrual cycles. Some women may get their periods every 3 weeks, others may miss several periods, and have only a period every few months or so in the years leading up menopause. Our point is, even while you're still menstruating you can still have miserable perimenopausal symptoms...

HIM
The first time it happened, I thought that it was one of those things that just happen to guys in their 50s. But when I had erection problems every time I tried to have sex, I could see that Lisa was getting worried about me. But I did not want to talk about it.

HER
"We'd be watching the commercials on TV for Viagra, and I'd be dying to say something, but I didn't for quite a while. But I knew that erection problems could be a sign of a health problem. Not to mention the fact that I missed sex. So I finally had to say something. I think Steve was actually relieved when I did.

Erectile Dysfunction (ED) is often an early symptom for many medical problems, especially heart disease. A 2006 article in the European Heart Journal found that ED can manifest itself two to three years before the onset of coronary artery disease, a primary cause of heart attack and stroke. To understand why, you need to know a bit about the mechanics of an erection.

When a man is sexually aroused, his brain sends a signal to the muscles in his penis to relax, so that blood can flow to his penis, specifically into the blood vessels and spongy tissue called the corpus cavernosum and the corpus spongiosum. This makes the penis hard, thus causing the erection.

But first things first. An erection is not likely to happen if a man is not aroused, and the ability to feel sexually charged is largely dependent on testosterone, the hormone that regulates sex drive. If a man doesn't have enough testosterone, even if he can get an erection for sex, he may not be very interested. Or if a man is very stressed out, or anxious about having an erection (which can happen after a bout of ED) it can also interfere with his ability to have an erection.

Similarly, if there is nerve damage, this can prevent the signals from the brain from being transmitted via the spinal cord to the penis telling it that he's interested in having sex. Nerve damage can be caused by a spinal cord injury, a stroke or even diabetes. After prostate surgery, it is not unusual for a man to experience erectile problems.

An erection is also dependent on good circulation: If blood flow is impaired in any way, it can interfere with the ability to get or sustain the erection. And here's where cardiovascular health comes into play. The arteries delivering blood to the penis are smaller than the coronary arteries delivering blood to the heart. This means that if a man is prone to developing atherosclerosis or clogged arteries, it is likely to strike the smaller arteries first because they will become narrow faster, thus blocking blood flow. That's why erection problems are often the precursor of heart problems.

Treating the root causes of the heart disease is often the first step in treating ED Bringing high blood lipids back to normal (lowering elevated LDL cholesterol, or high triglycerides) and reducing high blood pressure can help reverse damage to the arteries which will improve blood flow.

Medication is not our first line of defense. Losing weight can help improve blood lipids, especially if you are following the right diet. Regular exercise and weight loss can help lower blood pressure. As a side benefit, weight loss and exercise will also help normalize hormone levels. And while you're cleaning up your act, you're also feeling a lot better, which will make you want to have sex now that you're able to do so.

Below, we review our comprehensive approach for sexual dysfunction in men below. We're providing this information so that you can work with your doctor to help regain your health as well as improve your sex life.

First, we screen for any common medical conditions that could be interfering with libido and erectile function, such as hormonal imbalances, diabetes, heart disease, neurological disease and depression. We ask our patients to fill out detailed questionnaires on their medical history and lifestyle, and we follow it up with him a complete physical examination. It's important to be honest with your doctor and let him or her know any symptoms that you may be experiencing, sexual or otherwise. Your input can help your doctor make the correct diagnosis...

HER
"I suffered from heart palpitations, dizziness, difficulty sleeping and a whole lot of other unpleasant stuff. My doctor put me on anti-anxiety medication, which controlled my symptoms, but I felt dull and lethargic. I'm a business consultant-- I've got a lot of high powered clients, and I'd be sitting in meetings feeling really out of it. I wanted to get off the drugs."

HIM
"I thought that my wife was a nervous wreck, and I sought refuge in front of my computer. I worked all the time. I never realized that I was feeling just as badly as she was."

Barbara, an attractive, 52-year-old business consultant sought our help to get off the medication she had been taking for anxiety. It wasn't that the drugs weren't working: They did a good job of controlling her symptoms: heart palpitations, dizziness, muscle pain and difficulty sleeping. What Barbara didn't like was that the drugs also dulled her senses and made her feel lethargic--not exactly the image she wanted to project to her high powered clients. Barbara was looking for a different treatment approach that would still allow her to function at the high level to which she aspired.

Much of our practice revolves around helping people like Barbara better cope with mood related problems, including anxiety and depression. Although considered to be different psychiatric disorders, both anxiety and depression have a common link—they can be caused or aggravated by chronic and intense stress.

Stress is not all bad: Some forms of stress can be stimulating if not exhilarating. Learning a new skill or mastering a physical challenge can force you to extend yourself beyond the norm, and that can be stressful. People run marathons, climb mountains and tackle difficult tasks because they get some satisfaction out of the experience. But there's a real difference between good stress that motivates you to achieve new heights, and debilitating stress that weighs you down and can make you depressed and sick.

About 1 in 8 Americans-- about 25% of all women and 12% of all men--are diagnosed with clinical depression at some point in their lives. Anxiety affects about 4% of all Americans, and can occur simultaneously with depression.

Some people are genetically predisposed to these problems, but many others may succumb after a stressful period, such as a death of a loved one or a divorce. Mental health professionals used to make a real distinction between so-called "event" depression that would often resolve on its own, and "biological" depression caused by a biochemical imbalance. As we learn more and more about the biology of depression, we now know that there is very little difference between the two: whatever the trigger, the end result is the same.

Mood disorders are quite common, especially among midlife men and women. The physical changes of mid life, relationship issues, kids leaving home, work related pressures, financial worries, health concerns and the like can be extremely stressful.

Post menopausal women are especially vulnerable to anxiety and depression, and sometimes it's difficult to figure out whether the symptoms are due is a true mood disorder, or linked to hormonal imbalance. Whatever the root cause, mood disorders can disrupt your life, hurt your health, and damage your relationships. Medication can help, up to a point. And we use it when we have to. But simply popping a few pills is not going to do the job, at least for most people. Very often, the real "cure" is to solution is a lifestyle overhaul—a Mood Makeover.

We gave Barbara a thorough physical examination to rule out any underlying health issues. We then interviewed her at length to learn about her habits and lifestyle. To her credit, she had built her successful consulting business from nothing but hard work. Although she loved her work and was used to the long hours, she had noticed that in recent years, it was starting to take its toll. Like a lot of people with stress related symptoms, Barbara ate poorly, and gravitated toward "sugar fixes" to maintain her energy, which only aggravated her stress symptoms. And like a lot of people who are feeling overextended, Barbara wasn't happy about the extra pounds that she had put on recently, but felt she was too busy to deal with them. And now that her two daughters were away in college, she focused her energy on work, and she and her husband ate on the run. She didn't get enough exercise and rarely, if ever truly felt relaxed...

HER
"The weight just crept on me. I was a cheerleader in high school and a real fitness buff in my 20s, but the demands of work and caring for my family have made me neglectful of my diet. I don't watch what I eat, and I rarely get to the gym anymore. I used to care a lot about how I looked. I still do, but I don't think there is anything I can do about it. I think it really bothers my husband."

HIM
"Linda is very pretty, and okay, she may have put on a few pounds, but I am still attracted to her, and I want to have sex with her, but we just seem to be growing further and further apart. She won't even get undressed in front of me anymore. I feel badly for her and for us."

Midlife (ages 40 to 60) is the most difficult time in a woman's life to maintain normal weight. In fact, some seventy percent of women between the ages of 45 and 54 are either overweight or obese. In addition, visceral fat – the most dangerous kind -- is packed in a small region around your liver and other intra-abdominal organs. While the average woman may have 40-50 pounds of fat distributed throughout her body, somewhere between 5-10 pounds is intra-abdominal fat.

Women gain on average 5 pounds from perimenopause through menopause and many put on much more. The majority of women see their weight creep up slowly, usually right around age 50. After menopause, a woman's weight tends to accumulate in the abdomen. We feel this is partly function of the hormonal loss that characterizes menopause, when women's supplies of hormones – including (both) estrogen, progesterone, and testosterone – are depleted. In particular, testosterone, which is present in both men and women, helps maintain muscle mass and bone mass. The loss of muscle mass results in decreased burning of fat mass and the increased percentage of body fat that is typical for post-menopausal women and mid-life men. In addition, declining estrogen levels have been implicated as a contributory factor in the redistribution of body fat to the middle.

In women, excess body fat can lead to increased estrogen levels, which at first glance may appear like a good thing, but the evidence tells us that it isn't, particularly in regard to breast cancer risk. Some researchers theorize that the increase in breast cancer risk is due to an increase in estrogen feeding estrogen receptors on breast tumors. This may be so, but there are problems with that theory as a sole explanation. The science on this topic is still evolving, but our best determination is that the poor diet and lifestyle associated with obesity is having a profound impact on the estrogen by converting it to the toxic metabolites linked to breast cancer and ovarian cancers. (See page xx for a full explanation of how estrogen is broken down in the body.) In addition, it has been our experience that these metabolites can both have a detrimental effect on sex drive as well as aggravate PMS and menopausal symptoms, though research is needed to confirm these mechanisms.

We describe people who carry their weight around their middle as being shaped more like an apple than like a pear. Women whose excess fat tends to collect in the hips and buttocks are shaped more like pears, and, while they may rage against their heavy thighs, they may be at lower risk for life-threatening diseases than their apple-shaped friends. Wider hips, on the other hand, may mean you have bulkier bones and stronger thigh and buttocks muscles.

About 80 percent of women are more pear-shaped than apple-shaped before menopause. However, no matter what your body shape, the lower rates of heart disease that women under 50 enjoy in comparison with men disappear once menopause arrives. Talk about a change of life!

For men, unfortunately, the equation is simple: The more weight a man gains from age 25 on, the shorter his expected life span.

And in case that information wasn't enough to get you off the couch, we now know that a proven methodology to prolong the life span of living organisms -- from fruit flies all the way to humans-- is eating a very low calorie diet. Conversely, taking in more calories than you need, which results in overweight and obesity over time, shortens the life span.

Fat cells interfere with the normal breakdown of hormones in the body. In men, excess fat can contain increased levels of the enzyme aromatase which converts testosterone into estradiol. Estradiol can then be converted into a potent carcinogenic form of estrogen, which has been linked to prostate cancer. This aromatization process also lowers the levels of circulating testosterone, which has a negative effect on how a man looks and feels, and makes him tired, flabbier, and feeling decidedly unsexy.

Testosterone is the hormone that is essential for sex drive, erectile function and general. The diseases that are brought on by excess weight – especially in the abdomen -- diabetes, high blood pressure, high cholesterol, atherosclerosis – are exactly the same ones that can cause erectile dysfunction in men...

HIM
"She was driving me crazy all night. First she's too cold, then she's too warm, then she is cold again. I kept turning the thermostat up and down. Neither of us sleeps very well these days."

HER
"His snoring is so loud that I can't sleep. The whole bed vibrates from the noise! Most nights he sleeps in the den, and I hate it. I get lonely."

There are many theories about the purpose of sleep – including why we need it and what it does. Nevertheless, until recently, the importance of sleep was minimized. Biologists went as far as to suggest that the only purpose of sleep was to force our prehistoric ancestors to lay low at night so that they were protected from predators. We now know that there is much more to sleep than was once believed.

Sleep gives your body time to repair and renew itself. Your body systems wind down during sleep. Your metabolism slows. Your heart rate drops and so does your blood pressure. Your level of human growth hormone rises during sleep, and this stimulates the repair of old cells and the production of new ones. (Interestingly, exercise is another way to boost human growth hormone.) So, in a sense, sleep is a period during which your body de-ages itself. Missed sleep is a missed opportunity for rejuvenation.

Sleep is also a way of dealing with the stress of the day. Your brain is surprisingly active during sleep, and there is some evidence that while you sleep, you are actually sorting through the events of the day, processing information and even solving problems. During sleep, levels of neurotransmitters – important chemicals that help you think, learn and that regulate mood – are normalized. In contrast, when you don't get enough sleep, your body pumps out higher levels of cortisol, a hormone normally released during times of stress. This could explain why people who miss sleep are often so irritable and moody! And you know from chapter 5, "Can't Get it Up When You're Feeling Down," the damaging effects that stress hormones can have on all the systems of the body.

The sleep-weight connection is particularly intriguing. Studies show that people who routinely don't get enough sleep, which means about seven hours a night, are at greater risk for obesity. The question is why? Recently, scientists have discovered that sleep deprivation alters the production of metabolic hormones that regulate appetite, resulting in feelings of hunger. It's hard to refrain from eating if you're constantly hungry, especially if you are also fatigued from not sleeping. That's why we tend to overeat when we're tired.

Furthermore, chronic lack of sleep may increase the risk of adult onset diabetes, which is also associated with obesity. According to a 1999 study published in The Lancet, during a period of sleep deprivation, men's blood sugar levels took 40% longer to drop after eating a high-carbohydrate meal, and they were less able to respond to insulin, the hormone that regulates blood sugar and fat metabolism. Sleep deprivation also resulted in cortisol levels that were higher than normal, and thyroid stimulating hormone levels that were lower than normal. Notably, the hormone levels of sleep deprived people are similar to the hormone levels of much older people. Sleep is rejuvenating. Sleep deprivation appears to have precisely the opposite effect.

If you're losing sleep because you or your partner are having problems getting to sleep or staying asleep, it's important for both of you that you deal with it. Rest assured, there are things you can do to ensure that both of you get the good night's sleep that you need. The first step to solving the problem is getting to its root cause. There are numerous medical and emotional factors that could be keeping you up at night...

We work with couples individually and together, helping them to reconnect on an emotional level so that they could once again feel comfortable with physical intimacy. Not just in bed, but in all aspects of their relationship.

This part of the program shows you how to reboot your love life, re-establish intimacy and reinvigorate their relationship. It provides specific language and techniques to approach difficult and sensitive issues with your partner without making him or her angry and defensive...

Our diet is an extraordinarily potent tool to restore health, energy and sexual function in men and women. Within a short time, we see a dramatic improvement in hormone levels and cardiovascular risk factors (such as blood lipids and inflammatory markers.) Try our diet for 3 weeks, and we guarantee you will feel better than you have in years...

When it comes to dealing with sex, weight and mood problems, regular exercise is one of the most effective—if not THE most effective—treatment for all three problems. We offer a quick, simple exercise program that you can do alone or with your partner...

You've undoubtedly heard lots of information—and misinformation—on hormones. Here we present the pros and cons of hormone replacement therapy providing you with the facts that you (along with your doctor) need to make a smart decision. We believe that these decisions should be made on a case by case basis, weighing the risks versus the benefits, and based on a patient's family and medical history and lifestyle...

We believe that a good diet is critical for optimal health, and that supplements can't compensate for poor nutrition. We do, however recommend a select group of supplements that we believe can help rebalance hormones, help maintain normal metabolism and preserve health...

The role of stress is grossly underestimated in terms of its impact on your health, sex life and relationships. The Mood Makeover will show you easy ways to de-stress your life and boost your mood. The daily routine of simple breathing and relaxation exercises will keep you calm and focused...