18

DATING DANGERS

Have a positive sexual experience without testing positive

After a nasty divorce, 10-plus years of no sex, and then an attempt at intercourse that is beyond painful, you finally fix the issue and, miracle of miracles, meet a fabulous guy. A romantic dinner turns into an even more fabulous evening of amazing slippery sex on his couch. You change your status on Facebook and put your Match.com account on hold. Life is good.

And then, two weeks later, a funny discharge appears and you have a lower abdominal ache. Next comes the nerve-racking visit to the gynecologist, followed by the reality that along with the new relationship has come a new infection.

Every savvy woman needs to keep a few things in mind. If you have a new partner, unless he was a virgin before he met you, avoiding a sexually transmitted infection (STI) is a reality that comes with being sexually active.

And then there’s that other sexually transmitted situation that some women need to avoid . . . pregnancy.

Sexually Transmitted Infections Are on the Rise

Any sexually active woman can acquire an infection, but midlife women and women who date midlife men are at much greater risk for STIs than most people appreciate. Most of my patients seem to think that STIs are limited to 20- and 30-year-olds who are hanging out in bars or having random hook-ups. Trust me, it’s not as if these nasty bugs demand to see proof of age before infecting someone.

The primary risk factors for acquiring a sexually transmitted infection at any age are being unmarried, being sexually active, and having a new sexual partner. Over 50 percent of women over the age of 40 who have never been married or are divorced or widowed are in this category. There are over 50 sexually transmitted diseases, and the midlife woman is not spared. Women bear the consequences more than the guys since STIs are more easily passed from man to woman than from woman to man. If exposed, a woman is twice as likely as a man to contract hepatitis B, gonorrhea, or HIV. To add to the issue, women are less likely to have symptoms than men, which means diagnosis is often delayed or missed altogether.

A lot of women are reassured by the fantasy that the typical 50-year-old guy is “low-risk,” especially if he just ended his 30-year marriage. And that’s true if he and his wife were monogamous. But let’s get realistic. A lot of marriages end because someone wasn’t monogamous. It’s also not unusual for a newly single person to go maybe just a little overboard with making up for years spent in an unhappy marriage.

So many times my patients say, “I’m not worried . . . he’s a really nice guy.” I’ve got news for you. Sometimes the nice guys are the ones most likely to have an infection. Face it: creepy guys usually have a harder time getting someone to sleep with them.

There’s another reason why women who are postmenopause are at particular risk. Women with low estrogen levels and genital dryness have an elevated likelihood of acquiring an infection since vaginal tissue is thinner and more likely to tear during intercourse, allowing infection an easy portal. That’s why the age group in which STI rates are rising most rapidly is adults at midlife and beyond. The Centers for Disease Control and Prevention (CDC) reports that cases of syphilis and chlamydia rose 43 percent among US adults age 55 or older between 2005 and 2009. High-risk HPV is also on the rise.

One solution is to stay home, watch Sex in the City reruns, and stick to self-stimulation. A better solution is to know your enemy so you can protect yourself. Here’s a summary of the major bugs out there.

HPV

There are one hundred types of human papilloma virus (HPV), most of which are harmless. HPV is currently the most common sexually transmitted infection and is responsible not only for cervical cancer but also for vulvar, vaginal, anal, bladder, and some head and neck cancers. Did I mention genital warts?

HPV isn’t new; evidence suggests that ancient Greeks and Romans also suffered from problems related to HPV. There are 20 million documented cases of HPV in the United States each year, but the numbers are likely to be much higher since many people with HPV have no symptoms and don’t know they have it. While the highest prevalence of HPV is in 20- to 24-year-old women, who account for 45 percent of infections, a 2007 study in the Journal of the American Medical Association found that 27 percent of women between the ages of 25 and 39 had HPV. A 2004 study in the Journal of Infectious Disease focused on women up to the age of 85 and found that new infections occurred in every age group. While the lowest incidence of new HPV was in the over-45 age group, among those women there was still an infection rate of 12.4 percent. Currently, 80 percent of adults will have been exposed to HPV by the time they are 60. So, no matter how old you are, even if you’re a 75-year-old great-grandma, you may be at risk.

While precancer or cancer related to HPV is the most serious consequence of exposure, the most likely consequence of exposure is a crop of genital warts, also known as Condylomata accuminatum. Warts are upsetting. Really upsetting. It doesn’t matter if you are 24, 54, or 84. No one likes getting bumps all over her vagina that look ugly, are irritating, and need to be burned, lasered, or cut off multiple times. While it takes me only a couple of minutes to treat a cluster of warts with topical acid, I spend a lot more time trying to calm down a distressed, usually angry woman who has discovered a nest of “love bumps” all over her genitals.

Consider Sylvie’s story:

At 74, I had been a widow and not sexually active for over 15 years. As a birthday present, my son gave me a vacation on the QEII. During our transatlantic crossing, I met Hymie, and the attraction was instant. Such a happy ending . . . that is, until two months later when a garden of warts developed all over my genitals. This was a souvenir that I could have lived without. I refused to have anything more to do with Hymie and have been alone ever since, because I don’t want to tell another man that I have an STD.

Sylvie was my patient almost 15 years ago, and I will never forget how upset she was, how betrayed she felt, and how the STI kept her from ever initiating another relationship. It was very sad and, potentially, very unnecessary.

Condoms help prevent the transmission of HPV, but they don’t guarantee protection since transmission is possible through skin-to-skin contact, known as “outercourse.” Gardasil, a vaccine for women ages 9 to 26, guards against the four most common types of HPV. Gardasil is not FDA-approved for women older than 26, not because it is ineffective or dangerous, but because the FDA has determined that the “cost benefit” is not enough to make it worthwhile. Your doctor may be willing to vaccinate you (I vaccinate anyone who requests it), but in addition to sticking out your arm, you will need to stick out your checkbook since insurance won’t cover the cost.

Fortunately, most HPV infections clear up on their own, have no consequences, and require no treatment. Your best bet to avoid acquiring HPV is to use a condom. It’s also a good idea to do a thorough visual inspection before you turn off the lights. He will just think you are fascinated with his amazing package.

Herpes

Back in the 1970s, herpes became known as “the gift that keeps on giving” owing to the high recurrence rates years after the initial infection. Originally it was thought that if no sore appeared, herpes could not be passed on. While the risk of spreading herpes is highest during outbreaks, the virus is always present in the urinary and genital tract. Even during periods when no sores are visible, there is always the possibility of asymptomatic shedding when the virus can be transmitted between sexual partners. Once a sore does develop, the virus has been present and infectious for days before you could see anything.

The result? Infection is often transmitted unknowingly to susceptible partners. In fact, 70 percent of herpes infections can be linked to sexual contact when the “giving” partner had no symptoms.

There are two types of herpes. The first, herpes simplex virus type 1, is most commonly the cause of the oral herpes that is responsible for cold sores on the mouth and lips. The second is herpes simplex virus type 2, which is generally the cause for genital herpes. However, type 1 and type 2 can both be the cause of genital infection as a result of oral sex when there is a cold sore on the mouth of the “giver.”

The symptoms of genital herpes are generally most severe during the initial episode and get less severe in recurring episodes. During the first breakout, multiple blisters appear in the genital area and may continue to spread, with new lesions appearing for up to seven days. It is also possible to get blisters on other areas besides the genitals, such as your mouth and lips, during this time. Painful urination, swollen lymph nodes in the groin, and flulike symptoms are all part of herpes. Symptoms generally go away within two to three weeks. The virus will then go into the symptom-free latent stage and lie dormant in a bundle of nerves at the base of the spine, where it remains inactive.

Recurrences are usually much milder than the first outbreak. Some women experience pain, itching, or tingling in the legs, hips, or buttocks before a recurrent outbreak.

If you have no visible ulcers but believe that you may have been exposed, a blood test will detect if you are one of the 20 to 30 percent of sexually active adults who are asymptomatic carriers of herpes. Antibody responses to the virus take some time to build up in your body, usually about three to four months after the initial episode. So a herpes blood test may still have a negative result if you recently became infected. In other words, if you notice the funny sore on his penis after you have sex and get tested the next day, it is too soon to know if you were infected.

Once your blood test is positive for herpes, it will remain positive for life. It is also important to know that your herpes blood test will be positive if you have had a cold sore on your lip.

While there is no cure for herpes, suppressive therapy (taking an antiviral medication every day) not only reduces the likelihood of an actual outbreak but also decreases the chance of asymptomatic transmission. Once an attack begins, starting antiviral therapy as soon as possible will lessen the duration and severity of the symptoms.

If you are not already a carrier of the herpes virus, how do you avoid acquiring herpes? Abstain if your partner has any oral or genital lesions. If no sores are present, a condom should be used to prevent infection by asymptomatic viral sharing. If your partner is a carrier of the herpes virus, he or she should take a daily dose of an antiviral pill (available by prescription), such as acyclovir, valcyclovir, or famciclovir. Be assured, however, that you cannot get herpes by using his toilet, towels, or bedsheets or from sipping out of his wineglass.

If you are the one with herpes, you should take a daily dose of antiviral medication and insist on a condom to protect your partner, unless he already has it.

Gonorrhea

Gonorrhea has been, and still is, one of the most “popular” infections contracted during sexual intercourse. Roughly 700,000 people are infected in the United States every year. The bacteria, officially called Neisseria gonorrhea, can be passed on through the mucous membranes of the mouth, throat, anus, urethra, and vagina. It is not in sperm, which is why ejaculation is not necessary to infect someone.

As with almost every other sexually transmitted infection, many people with gonorrhea have no symptoms at all, which is why carriers unwittingly spread the infection before they know they have it. Symptoms that indicate a possible gonorrhea infection include burning during urination, sore throat, abnormal discharge, vaginal itching, bleeding between periods, and infection of the uterus, fallopian tubes, and ovaries. It’s important to get screened for gonorrhea regularly. Your doctor can test for it from a cervical swab or a urine test.

If you are not aware that you have gonorrhea, you may end up with gonnococcal arthritis or a joint infection. You can also get a pelvic infection, which can be serious enough to require hospitalization and maybe even surgery. Gonorrhea treatment is a onetime antibiotic treatment with either a shot or a pill.

Chlamydia

Chlamydia is the most common sexually transmitted bacterial infection. Four million cases of Chlamydia trachomatis occur every year. The bacteria can be passed on through the mucous membranes of the mouth, throat, anus, urethra, and vagina, and ejaculation is not necessary to spread it. Contrary to popular belief, chlamydia cannot be transmitted via inanimate objects such as a toilet seat. (Are you feeling better about public toilets yet?)

Some people with chlamydia have no symptoms at all, but there are several symptoms that indicate a chlamydia infection:

•   Abnormal discharge, abdominal pain, or bleeding between menstrual periods

•   Pain during intercourse

•   In women, an infection of the urethra causing symptoms similar to a urinary tract infection, including a frequent urge to urinate, burning during urination, and low abdominal pain

•   Pelvic inflammatory disease

Chlamydia can be detected by a urine test, with a cervical swab, or with a self-administered vaginal swab. It is easily treated with an oral antibiotic.

Hepatitis

Hepatitis is simply inflammation of the liver. There are multiple types of hepatitis, but the form of this virus that is most commonly spread by engaging in unprotected sexual intercourse is called hepatitis B. This virus can survive outside of the body for a long period of time, so personal items such as toothbrushes and razors can also carry it.

A vaccine is available to protect against hepatitis B and can also be administered after exposure. Signs of hepatitis include right-sided abdominal pain, nausea, vomiting, fatigue, and the whites of the eyes turning a rather unattractive shade of yellow (the most characteristic sign). If your blood test screens positive for hepatitis, you will be referred to a specialist who treats liver disease.

HIV

HIV, or human immunodeficiency virus, weakens the body’s immune system, which makes it difficult to fight a multitude of infections and cancers. When the infection is in its most advanced stages, it is called AIDS (acquired immune deficiency syndrome). Without treatment, HIV can cause extreme illness and death. While this is probably the infection that my patients are most concerned about, it is also the infection I diagnose most rarely. Not to minimize the importance of HIV transmission, but the statistics are relatively low for transmission in a heterosexual or lesbian relationship. Having said that, the consequences of this virus are grave, and therefore screening and prevention are critical.

It is possible to have HIV without having any symptoms. Even without symptoms, the illness can be passed on through sexual contact or exposure to contaminated needles. The CDC recommends at least one screening blood test in every sexually active woman, and repeat tests in the event of a new partner. When a test is positive, it is confirmed with another test. One can be tested for HIV at any time, but it is suggested to have a repeat test done at 6, 12, and 24 weeks after suspected exposure.

Syphilis . . . Not Just of Historical Interest

When Christopher Columbus discovered America, among the gifts he brought from the Old World was one of the oldest known sexually transmitted diseases . . . syphilis. Al Capone, Adolf Hitler, Scott Joplin, Ludwig von Beethoven, and Abraham Lincoln are all included on the list of famous people alleged to have had this infection, caused by bacteria known as Treponema pallidum.

Today, when I suggest to someone that they consider a blood test for syphilis as part of an STI screen, they look at me like I just escaped from the 19th century. Syphilis rates were sky-high in the 1940s but dropped precipitously when penicillin became available for treatment. In 2001 the incidence started to creep up again, but it seems to have leveled off since 2010.

Many people are unaware of the sore that erupts in early syphilis, or they assume that it is nothing to worry about. This painless open sore is called a chancre (pronounced “shanker”) and is often found in the genital area, anus, or mouth, but it can be found wherever the bacteria entered the body. After the initial phase, four to ten weeks can go by without symptoms until the second stage occurs; then a rash, fever, or enlarged lymph nodes appear. Secondary syphilis is highly contagious through direct contact with the mucous membranes. If still unrecognized and untreated, tertiary syphilis, the most serious form, can develop one to 30 years later, resulting in neurologic or other life-threatening problems.

Once someone is infected with the organism that causes syphilis, it is highly contagious. While most people are aware that the infection is passed on by intercourse, kissing or touching an active sore on the lips, breasts, or genitals can also transmit it.

How to Protect Yourself from STIs

I Use Condoms, I Have Nothing to Worry About, Right?

Wrong. The reality is that condoms are not foolproof. First of all, the HPV and herpes viruses are not in semen but live on skin, so intercourse is not necessary to transmit them. Since a condom covers only the penis, short of strapping on a hefty bag to cover a man’s scrotum, anus, and surrounding skin, there is no such thing as total protection.

In general, my patients are very responsible and hyper-aware that infection can be prevented by being vigilant about condom use. In spite of that, studies (and my experience talking to my very responsible, hyper-aware patients) show that single women in midlife who have two or more sexual partners rarely report consistent condom use.

Here’s why: Older women are generally dating (surprise!) older men. The older a guy gets, the more difficulty he’s going to have getting and maintaining an erection under the best of scenarios. Add a few glasses of wine and a condom, and it’s game over. The reality for many men over the age of 60 is that putting on a condom often puts an end to the party, and if a woman wants to get anything accomplished, she often has no choice but to forgo any extra distractions. Since contraception is no longer much of an issue, and a good man is hard to find, but a hard man is just about impossible to find, she usually puts up less of a fight.

Dr. Streicher’s SexAbility Survey

Single women were asked what they would do if a new partner was not able to maintain an erection with a condom.

47.2 percent said, “Break up. It’s not worth chancing a sexually transmitted infection.”

38.2 percent said, “I’d have sex, but not intercourse.”

14.6 percent said they would forget the condom and hope for the best. (After all, he’s a really nice guy.)

So while my patients all intend to use condoms, they often don’t, since the situation can be “lose the condom or lose the guy.” In addition, many of these men and women became sexually active during a time when STIs were not such a heavily discussed issue, so while they intellectually are aware of the risk, emotionally they really don’t put themselves in the category of someone who might catch an STI. (This is where the “he’s a really nice guy” rationalization comes into play.)

I’m not going to tell you what to do, but I can tell you that I see and treat a lot of infections in women who decided to skip the condom “just this once.” But you can also take matters into your own hands! The female condom has not yet caught on, but it is a very viable option. The FC2 condom (formerly known as the Reality Female Condom) is a nonlatex (the same material that’s used for surgical gloves), very soft, thin sheath that lines the vagina and not only covers the cervix and vaginal walls but also shields the outside of the vagina. An FC2 condom can be bought over the counter and prevents both infections and pregnancy. No special fitting is needed: one size fits everybody. There is a ring on the outside of the condom that prevents it from getting pushed inside the vagina during intercourse and also provides protection during oral sex. And as a bonus, many women report that the ring stimulates the clitoris and enhances arousal.

It goes without saying that you should not depend on the man to come prepared. You should have an assortment of male condoms on hand. Be sure they are all marked “extra-large.”

Saran Wrap Is Not Just for Food

When HIV first became a health hazard, there was a lot of buzz about using dental dams as protection during oral sex. Dental dams are small sheets of latex that are intended for dentists to use, but they can also be placed on the outside of the vagina during oral sex. But have you ever seen dental dams in a store? Have you ever actually spoken to someone, other than a dentist, who uses dental dams? Neither have I.

It’s actually easy to make your own version of a dental dam. Simply take an unlubricated condom (one he’s not using!) and cut off the tip. Then cut through one side of it to make a square of latex, which can then be stretched over your vulva.

Another popular alternative to dental dams is plastic wrap, as in the plastic wrap that is intended for food storage. That’s right. Many women stretch a piece of plastic wrap over their vulva to prevent any diseases that lurk on his (or her) tongue from infecting their vulva or vagina. I have even been told that the wrap increases sensation. So the next time you are in your grocery aisle and the lady in front of you has just put a jumbo box of plastic wrap in her cart, consider that it may not be for her leftovers.

But buyer beware: plastic wrap intended for food has never been tested for this other purpose, and there is concern that products intended for microwave use may be too porous to keep out HIV and other infectious bugs. You are probably better off cutting open a condom or using a female condom.

A Few Other Tips for the Savvy Dater

One recurrent theme here is that the majority of these infections have no symptoms in their earliest stages. That’s why screening is so important. And no, screening for STIs is not done automatically when you go to your doctor, nor is it part of a Pap test. So, if your doctor doesn’t mention this, you need to ask. You don’t need to go into lengthy explanations about the guy you slept with though you probably shouldn’t have, or about the indiscretion with your coworker. Simply say, “I would like a screen for sexually transmitted infections today.” If your doctor doesn’t tell you what he or she usually screens for, ask.

If you are having any symptoms, or know that a sexual partner had an infection, by all means mention it. Your doctor will not be shocked. Really. If for whatever reason you prefer not to mention it to your doctor, Planned Parenthood and your local board of health clinics will perform confidential screening.

If you are diagnosed with a sexually transmitted infection, it is important to inform all your current or recent sexual partners, so that they can also be treated. Even if the guy is a jerk you never intend to see again, consider the next woman he might sleep with and do her a favor.

Preventing Pregnancy! Are You Kidding?

Young women are well aware that a possible consequence of having sex is pregnancy. It’s the woman who is perimenopausal who often thinks she does not need to worry about inadvertently conceiving. And that may be true. If it has been more than 12 months since your last menstrual period, you have had a hysterectomy or tubal ligation, you’re using reliable contraception, you’ve been infertile before, or your guy has had a vasectomy, you can skip this section. But if you are not in any of those groups, read on.

Roughly 40 percent of pregnancies in the United States are unintended. Not surprisingly, the highest rate of unintended pregnancy is among women aged 24 and younger. Surprisingly, the second-highest rate is among women over 40. In fact, unplanned pregnancies in women over 40 have recently increased because so many women in that group assume they are no longer fertile.

Creep Alert

I know this will shock you, but . . . not every guy is 100 percent honest. (Gasp!) Just because a guy says he’s been “fixed” doesn’t always mean he’s been fixed. I have had two patients who conceived after having sex with a boyfriend who insisted that no protection was necessary.

Most of my patients assume that the further they are on the other side of 40, the less the need for contraception. It’s correct that fertility dramatically declines as time marches on: just ask any 40-year-old who is trying to get pregnant. But “declines” is not the same as “disappears.” While pregnancy is a lot less likely after 40, it can, and does, happen.

Doctors Know That . . .

. . . 75 percent of pregnancies in women over 40 are unplanned.

Think about it: Geena Davis was 48. Madonna was 44. Jane Seymour was 45. At first glance, you would think that these are the ages at which these celebrities won an Oscar, not the age at which they had a baby. Of course, most midlife pregnancies are a result of in vitro fertilization, using a donor egg from a younger woman. But some women do spontaneously conceive in their forties. While the number-one predictor of fertility is age, there is a significant variability in ovarian aging: some women are infertile at 35, while others are still going strong at 45. That’s why contraception is still needed, unless an unplanned pregnancy would not be the end of the world.

Genetics definitely plays a role here. Even if you have nothing in common with your mother, her hormonal pattern is frequently predictive of when you are genetically destined to wind down your fertility. If your mom went through menopause late, you are likely to do so as well—which usually means you will be fertile longer.

The best test of fertility is to become pregnant. Short of that, here are the indicators of your current fertility and of how long you will be fertile:

Clockwork periods: While regular menses are not a guarantee of ovulation or fertility, it is a pretty good indicator that your ovaries are pumping out estrogen, releasing an egg, and then producing progesterone. Obviously, if you are on the pill, regular periods don’t count.

Blood hormone levels. Measuring your blood FSH (follicle-stimulating hormone) level is helpful. A low FSH level correlates with good ovarian function and high estrogen levels. A midrange level means things may be winding down, and very high levels usually indicate that the ovaries are out of business. But FSH levels do not steadily decline; they fluctuate from month to month, particularly as women get older. An FSH level tells you where you are hormonally on the day you take the test; it does not predict how long you will stay at that level. Until FSH has been above 30 IUs per milliliters for 12 months, a woman should still consider herself at risk for pregnancy.

Anti-Müllerian hormone. Anti-Müllerian hormone (AMH) is the newest way, and probably the best way, to evaluate a woman for ovarian reserve—that is, how good your eggs are and how long they will continue to be functional. AMH is secreted by cells from follicles in the ovary. Follicles are only present if healthy eggs are still around. AMH declines with age as the “good” egg pool declines, and it’s completely gone after menopause. Unlike other hormones used to measure fertility, AMH doesn’t vary through the cycle and can even be measured in women who are taking birth control pills. While AMH blood level is a reliable way to know what your ovarian reserve is, there is no consensus as to what the lowest level is that indicates you don’t need contraception. In general, if AMH is above 0.5, there is good ovarian reserve and contraception is needed.

Fortunately, if you are a midlife woman still at risk of pregnancy, you have a lot of options.

Contraceptive Options at Midlife

Barrier contraception is still the go-to method for most women. Yes, I’m referring to condoms. Readily available, easy, and safe, condoms are a tried-and-true method that works. The bonus is that they also protect against sexually transmitted infections if that is an issue. The main limiting factor is that some men don’t want to use them.

Diaphragms seem primitive, but they still have a place. A side bonus for the midlife woman is that the diaphragm sometimes gives a little support to the urethra and helps with incontinence! There are other barrier methods, such as the female condom, the cervical cap, and the vaginal contraceptive sponge, but like condoms, they all need to be used correctly and consistently. I’m a big fan of long-acting, set-it-and-forget-it methods, such as intrauterine devices and Nexplanon.

Hormonal Contraception

Many women think that the pill is not an option for the over-35 crowd, but contrary to popular belief, healthy, normal-weight women who are nonsmokers can safely use hormonal contraception, such as the pill or vaginal ring, up to age 55. The newest pills contain minuscule amounts of estrogen compared to earlier birth control pills and therefore have a much lower risk of complications such as blood clots or stroke.

In addition to preventing pregnancy, hormonal contraception has a number of noncontraceptive benefits that are particularly relevant to woman over 40. These include less pain with periods, lighter periods, and, best of all, a significant decrease in ovarian and uterine cancer. In addition, taking a low-dose birth control pill is an excellent way to regulate the erratic periods and crazy mood swings that are part of the perimenopausal hormonal roller coaster. The downside is that in a small but very real percentage of women, hormonal contraception can cause vaginal dryness and decreased libido. For more detailed information on birth control options, refer back to chapter 12.

Good to Go!

So now that you are ready to have safe sex (and are not too freaked out, I hope, by the possibility of acquiring an infection), it’s time to have fun sex. Confidence is a huge part of that equation. Not a day goes by that I don’t see a midlife patient who is reentering the dating scene after a long hiatus and feeling more than a little trepidation. Childbirth and time (and gravity!) are not always kind to women’s thighs and butts, and many women express at least some insecurity about the appearance of their middle-aged body. That’s understandable, since many women who reenter the dating scene are not only 20 years older than the first time around but at least 20 pounds heavier.

If you are feeling less than confident about the appearance of your body, there are a few things to keep in mind:

•   The guy you are dating is likely to be the same age as you, or even a few years older, and he won’t look like his 20-year-old self either! His six-pack will probably have morphed into a not so attractive one-pack.

•   Older guys don’t have great eyesight.

•   There is no such thing as owning too much beautiful lingerie. Wear it even if you are not planning a sexual encounter.

•   Candlelight is essential. Not only is it incredibly romantic, but everyone looks more attractive.

So turn out the lights! But not before you read chapters 19 and 20.