DEAR DR. NERDLOVE: I know you’re not a real doctor, but I’m hoping if you can’t answer my question, maybe you can help me figuring out how to get recommendations from someone who can.

It’s this: I have been dealing with (and trying to treat) chronic tachycardia for a bit over a year now. Recently (past six months or so) it seems like orgasm or even nearing orgasm triggers a cardiac event (usually acute rapid heartbeat and I pass out). I’m not sure exactly, because honestly after it happened twice, I just stopped nearing orgasm during sex/masturbation. I tried last night, though, and I triggered the tachycardia. Fortunately, didn’t pass out, but I felt physically awful afterward.

So: is there a way to orgasm slower?

Or, maybe reduce the risk of rapid heartbeat, maybe ramp up more slowly?

Or maybe, I don’t know, is there a mildly calming drug or supplement that can temporarily slow down heartbeat but keep sex drive going?

Yes, I know, I will not take anything without talking to my cardiologist. But I’m looking for any direction or options.

For context, the chronic tachycardia is likely either a complication of a condition I’ve had since birth, or a side effect of the medication I’ve taken for it for decades. In cardio rehab, physical therapist determined a walking speed of 3.0 mph, for 4 minutes, creates a sustained tachycardia that causes me to pass out and my blood O2 to drop. So… that’s annoying. I have to pace myself at, like, 2.5 mph or slower to walk for half an hour.

Also, I am a cisgender woman, married to a very sexy cisgender man, we’re both mid-30s, and our sex life is solid other than this issue. My husband is honestly more cautious and in general is more into sensual-erotic intimacy that doesn’t necessarily lead to orgasm anyway. Which I also enjoy!

But I also enjoy and desire overtly sexual experiences, including orgasm, pretty frequently. I don’t want orgasm to be completely off the table (even when masturbating?) just because my heart gets too into it!

I have not brought this up to my cardiologist or physical therapist, because it’s extremely awkward. What do I even say?

Also, I feel like it sounds whiny or entitled. Like we’re focusing on preventing a heart attack, or keeping my condition stable so I won’t need a transplant in a few years, but I’m upset because I can’t have a specific sexual experience?

Maybe my question should be, “how do I set aside this desire and be happy with what I have?”

I don’t know. Any advice is welcome.

Heart Is Actually Broken

DEAR HEART IS ACTUALLY BROKEN: I know you said this at the start of your letter, HAB, but I want to repeat this for emphasis: Dr. NerdLove is NOT a real doctor and this is very much something that you need to talk to your doctor about. I’ve got friends with similar issues, and they’ve provided some insight into options, but you absolutely need to be talking to your doctor about this.

Here’s the thing: tachycardia is no joke, and it can present serious issues for people’s day to day lives. Managing it and keeping it under control requires a lot of care and attention. But it also means that you have to be willing to speak up when these issues are causing problems in your life. One of the issues a lot of women in particular have when dealing with doctors and people in the medical field is feeling like they can’t speak up and advocate for themselves… and with good reason. A lot of women find it difficult to get medical professionals to take them seriously, especially if they’re addressing concerns they have with a particular treatment or medication and the effects it may be having on their lives. It’s very easy to get discouraged when a person in a position of authority tells you that it’s not a big deal, all in your head, or something that you should be able to just deal with.

The thing is: you’re the expert on you, and you’re the best authority on what you’re experiencing and how it’s affecting you. So, as scary and as hard as it can be, you want to get in the habit of being your own first line of defense and most zealous advocate, especially with things that are affecting your overall quality of life.

And sex, sexual pleasure and intimacy with your partner are all very much a part of your overall quality of life, not things that should be dismissed or hand waved away. So while it can feel awkward to bring this up, it is something you should be willing to advocate for. Now, maybe you would need to bring your husband as both your moral support and advocate, especially if your doctor isn’t willing to listen or take things seriously. It may be, for example, that the doctor would be more willing to listen if your husband repeats what you said. As absurd as it is and as screamingly sexist as it is, “what she said, but with a penis” is often the only way to break through the systematic sexism that infects so much of life. But also having him with you and knowing that he’s going to back and reinforce your play can give you the additional boost to say what you need to say.

I would recommend memorizing the following phrases and using them as needed: “this affects my relationships, my productivity at work and my overall quality of life”, “what would you recommend for a male patient experiencing these symptoms” and “will you please make a note in my records that I requested this, and you refused?” 

I would also suggest that your husband be ready with “don’t ask/tell me, ask/tell her, she’s the patient.”

Now that having been said, there’re a few things that you can try. The first is: hydrate. Seriously. Treat sex like any other form of physical activity and stay hydrated. The next is realize that certain positions may not be good for you. On your back or on your side can work. On top, with the level of effort and motion needed is likely to be how you end up meeting the local first responders while naked – something you probably want to avoid. Rear-entry positions where you’re bent over or on your knees are less likely to be as risky, but still not great.

You mention that your husband is more into sensuality; that’s good, because it’ll be easier to keep things at a more measured pace. Hard and fast is almost certainly going to be off the table, so a long, slow build-up is going to be the way to go.

As cheesy as it may sound, you may actually want to look into some tantric practices. Focusing on sexual activity where breath control and gradual arousal are prioritized can be good for getting you where you want to be without hitting the danger zone for your heart. The same goes with masturbation; a longer, slower and more gradual build up will likely be better for you than going to town with a high-speed, high-intensity vibrator. If you’re someone who needs direct clitoral stimulation, then something that can give a low buzz and let things build without getting your circulatory system worked up may be helpful.

But again: you really need to be in the care of a cardiologist and discussing options with them – including what side effects you’re not willing to tolerate. A lot of heart medications will tank the libido, which may keep your tachycardia under control but works against your goal of a fulfilling sex life with your husband.

It can be hard to speak up about something so personal, I know. But if it’s important to you – and it certainly sounds like it is – then you should make that clear. Even if your voice quavers and your knees shake while you’re doing it. To paraphrase a particular general: be afraid… but do it anyway.

Good luck.

Please send your questions to Dr. NerdLove at his website (www.doctornerdlove.com/contact); or to his email, doc@doctornerdlove.com

DEAR DR. NERDLOVE: I was hoping a fresh perspective from someone who isn’t my therapist could help me. I’m 28, have had one girlfriend in college, and have otherwise never talked to a single girl in my life (she approached me). Granted, I wasn’t particularly attracted to her physically or emotionally, but I wasn’t about to squander my chance to lose the V card, so we had our fling for about 6 months and then amicably/mutually split.

Whether it’s making a dating profile, or approaching a woman with romantic intent, I have a full-fledged panic attack/meltdown. Trying to get me to date is like that scene in Rain Man at the airport when Tom Cruise tries to get Dustin Hoffman on the airplane; he protests, he’s unsure, he is anxious, and when Tom Cruise tries to force Hoffman onto the plane, he has a full-fledged meltdown at the gate. I have a similar response with expressing any modicum of romantic intent. I lose all sensibilities and will claw, kick, and punch to get me the F--K OUT OF THERE! I know nothing worse than a bruised ego will happen if I approach a woman, I know I won’t be cast out from society if I make a dating profile, I know that women desire men, and I’m not an unlovable monster nor a creep for making advancements. I have no logic to attach to these overwhelming feelings.

I am currently (and have been for about 3 years) medicated on an NDRI and an anti-psychotic for major depression/anxiety with NSSI tendencies that I’ve exhibited since I was a kid. My therapist and I have explored many angles to no avail such as exposure therapy to just outright taking the plunge and have all resulted in the same thing: a meltdown. I can talk to girls I am not attracted to and/or when there’s zero chance of any non-platonic engagement. But the expression of romantic intent on my end sends shockwaves of panic through me. I do want to find love and build an amazing life with a woman and stem the tides of loneliness, but I’ve yet to vault this lifelong wall of a hurdle. I’m hoping you’ve seen this before or you could provide some unique perspective.

From,

Man of Many Meltdowns

DEAR MAN OF MANY MELTDOWNS: There are a lot of times when people use hyperbolic language to describe the level of fear or anxiety they experience when dealing with an intimidating or scary experience. This can actually make things harder, because a lot of terms in casual use have actual medical meanings and definitions. As a relevant example, people will use the term “panic attack” to describe the mundane feeling of “this makes me very upset and anxious, makes me nauseous and gives me knots in my stomach”. The problem is… that’s not a panic attack. In medical terms, people who are experiencing panic attacks often mistake the symptoms – chest pains, numbness in the extremities, hyperventilating or an inability to breathe and an honest, intense sense that they are literally about to die – for heart attacks.

This is one of the reasons why it can be important to really think about your word choice and how you describe what you experience. There’s a world of difference between an anxiety attack and a full-bore panic attack and conflating the two makes it much harder to tell someone what to do about it.

So MOMM, I’m going to assume that when you say you have a full-blown panic attack, you mean you have a literal, physical fight-or-flight response that feels like you are going to die. Because otherwise… well, this is one of those times when exaggerating for effect or overstating what you’re actually experiencing can get in the way of actual help.

The first thing I would ask is whether you’ve talked to your prescribing physician about the medications you’re taking. You want to first make sure that there aren’t any side-effects that may be affecting you. A number of NDRIs, for example, can increase anxiety. It’s not common, but it can happen. I’d be more worried about whether it’s having an adverse interaction with your anti-psychotics.

The second thing I would suggest is that, after having double checked that your meds aren’t the cause, to think carefully about how these attacks come on. There is a significant difference if, for example, it’s something you feel ramping up or if it’s an abrupt, binary state. Is it that you can talk to someone but if there’s any romantic or sexual interest, you feel the panic come on? Or is it the equivalent of someone saying the words “Niagra Falls” and suddenly a switch in your brain flips. That might tell you a bit more about precisely where the issue is and how to deal with it.

If it’s more of a ramping up, then what you’re going to want to do to start is focus on the symptoms. One of the keys to managing anxiety and panic is to remember that the body rules the brain, not vice-versa. Our brains respond to the input our bodies give; when we feel the symptoms of a feeling, such as an elevated heart rate, a dry mouth and sweaty palms, we don’t immediately assume we’re afraid; we feel the physical sensations and then ascribe a reason to them based on what’s happening around us.

Part of why this can be important is because it means that controlling the symptoms means controlling the feeling. The racing heartbeat and rapid shallow breathing is your body flooding your blood with oxygen and adrenaline, getting you ready to fight or flee. But if you control your heartbeat, you change how you feel. Without that racing heartbeat, you aren’t going to be as afraid. You may feel a more intellectual anxiety – something more abstract – but you aren’t feeling like you’re in immediate danger of death or injury.

So if these attacks start by ramping up, even if they ramp up very quickly, then part of what you want to do is focus on your breathing. If you control your breath and force yourself to breathe in a measured, controlled way, you force your heart to slow down. Slowing your heartrate down decreases your level of fear and anxiety. Controlling your breathing like this also forces you to be present – you’re having to divert your bandwidth to being aware and mindful of your body. This helps pull your attention away from the hypotheticals that are causing you to have this sudden surge of fear.

You want to do four-count breathing; breathe in for the count of four, hold it for the count of four, then breathe out for a count of four. Keep doing this – in slowly, hold it, out slowly – until you feel the panic start to subside. It can take some time to get used to doing this with a measure of control; after all, when you’re in full freak-out mode, you’re not thinking rationally if you’re thinking at all. Practicing this technique, especially when you’re feeling the early stages of this panic, can help you turn that into muscle memory, something you do on autopilot, rather than something you have to remember to do.

The next thing I would do is talk to your doctor about the possibility of beta-blockers. These prevent adrenaline from coming in contact with the beta-receptors in your heart, keeping the adrenaline from making your heart pump faster and spread the adrenaline through your system. Beta-blockers are usually prescribed for managing heart disease, but they’ve long been used off-label for managing anxiety and keeping people calm in stressful or dangerous situations. This can help keep you from melting down just because you think someone’s cute and want to ask her for her number.

However, this is emphatically needs to be discussed with your physician first, because you want to make double and triple sure that this isn’t going to have any interactions with the meds you’re taking.

The last thing I would suggest is that you need to address the actual triggers. After all, controlling the symptoms is just that: controlling the symptoms, not the source. They’re a bandage, not a cure. The issue at the heart of this is why you freak out. Maybe it’s something residual from the woman you dated – the one you said you were only with because you wanted to lose your virginity. There may be lingering issues there; feelings of guilt because you feel like you were using her, feeling like you did something wrong by being with her when you didn’t like her, even the possibility of trauma from trying to force yourself to be attracted and to want to be with her.

Or there could be something else entirely. That’s for you and your therapist to dig into, not a loudmouth with an advice column.

Now there’s one thing that I think you may want to consider and that’s that you may need a different therapist or a different form of therapy. One of the things folks often don’t realize is that not every therapist is going to be able to help with their particular issues, nor is their form of treatment helpful or appropriate for the condition they’re dealing with.  

Sometimes it’s a matter of needing a different therapist; therapy is, in some ways, a lot like dating, and you need someone you actually click with and work well with. But other times, it’s a matter of needing a different tool for the job. Some mental health issues respond to medicine, some to talk therapy and others to things like cognitive-behavioral therapy or other techniques.

Think of it like trying to accomplish a particular task. You could, for example, use a knife to cut a tree branch… but you’d accomplish it a lot faster and more efficiently with a saw. So it is with therapy. Some treatments can work, but not as well; others are functionally useless for the issue you’re dealing with.

You’ve mentioned that talk therapy and exposure therapy haven’t helped. It may well be that you need to try something a little further afield. If this is akin to something like PTSD, then maybe what you need is to look into treatment like EMDR. This form of therapy was created specifically to alleviate the fear and pain from traumatic memories and experiences; it’s been used to great effect with first-responders, combat veterans and other people who’ve dealt with the sorts of situations that f--k people up for life.

This isn’t necessarily for everyone, and you may well not be a good candidate for it. But talking about this with your therapist and looking into other therapy options may be helpful if what you’ve been doing thus far hasn’t worked.

Now I know a lot of folks have a hard time telling their therapist that what they’re doing isn’t working, much as people have a hard time telling their doctor that the treatment they’ve been prescribed isn’t helping. There’s an understandable feeling of “well, maybe I’m not doing the work/ not doing it hard enough/ not doing it for long enough”. But the only person who knows what’s going on in your head is you. If you know that things aren’t helping or are causing other issues, then you have to be your own first and best advocate for your own needs.

But first, start with talking to your prescribing physician to rule out drug interactions and work on controlling your breath. If you can manage to get things under control this way, then you’ll have a lot more available bandwidth to start digging into the root of the problem and addressing things from there.

Good luck.

Please send your questions to Dr. NerdLove at his website (www.doctornerdlove.com/contact); or to his email, doc@doctornerdlove.com

DEAR DR. NERDLOVE: I am a 45-year-old single woman, also a mom of an elementary school child. I’m pretty good looking, fit, I think I’m smart and funny. I have close relationships with friends and family, and don’t often feel lonely (I’m an introvert).

I honestly think I could be contentedly single forever, and that might be my fate.

However, it saddens me that I never found a person who loved me in that way. It seems… unfair. I’m no better or worse than any of my friends who found love.

While I am aware that I can certainly “get back out there” if I wanted, my concern is that the idea of dating fills me with dread. I dated before and even after I had my child and had some good times and some not so good. But it was never a joyful experience.

I don’t relate well to men I don’t know at first (I guess I’m shy, you could say). Plus, dating is time consuming, and I’d often rather do anything else then spend a week or more texting, then arranging a date, then going out and having the date.

And feeling rejected on the rare occasions I’ve felt connection, hurts more than I think it’s worth.

So, the larger winning part of me is content to swear off dating and the possibility of romantic love; I’ll choose to find ways to be happy.

But I guess there is still a piece of me that must want a partner, otherwise I wouldn’t occasionally wonder if I should be dating or wondering if there really is someone out there that I’m supposed to meet someday or wondering why I’m a person who wasn’t destined for romantic love.

Do you have any insights for me?

Still Single After All These Years

DEAR STILL SINGLE AFTER ALL THESE YARS: Let’s start off with something obvious, SSAATY: you are already doing what I tell people they should do if they want to be content whether they’re coupled up or single and that’s awesome. A good life with friends, passions and interests and having your needs met for companionship (and solitude when you need it) is something we should all strive for, regardless of our relationship status.

Now you, as many people who are in that situation, have found that this doesn’t mean that you don’t necessarily want a lover or a life partner; it just means that you have a good life whether you have one or not. And that matters, because it helps keep things in perspective: having someone to share that life with is an enhancement, not a necessity for happiness or contentment or satisfaction.

But here’s the thing about love that I think you need to remember: it’s not about deservedness or fairness. Love isn’t a reward granted by the universe to people who meet certain standards or tick particular boxes. It is, to a certain extent, a matter of probability – a matter of right person, right place and right time all coming together in a particular way. We just happen to take it very personally.

Is it your fate to be single for the rest of your life? Maybe. Or it might not be. Always in motion, the future is, and it’s impossible to say for certainty. You could be hit by a meteorite tomorrow. Or you could meet the love of your life when you’re both 70 and complaining about the quality of the Sunday brunch in your retirement community. Or anything in between. Nobody can say.

What I can say is that if you want love, you don’t have to be treat finding it like you’re planning an expedition to the Congo to find the Mokele-Mbembe.  I mean, you can put yourself out there if you really want. You can get on the dating apps, sign up for the single’s run clubs that’re starting to take off, go to speed-dating events or start hitting up cocktail lounges and flirt with strangers if you think it might be fun. But it sounds like you don’t, and that’s fine. That’s not the only way to meet people, especially considering that you know you’re someone who tends to be a slow burn.

Instead, what I would suggest is to just… live your life. But to live it in a way that makes it more likely for you to meet people who you would want to date.

One of the (many, many) reasons why folks often get frustrated with dating is because they treat it like a race, or like you’re interviewing candidates to fill a role. They get hung up on the end point – having A Partner – and so the outcome takes on outsized importance. They have turned Finding Someone into something that becomes more significant than the eventual someone and that can be corrosive to the soul. Yeah, we’ve all heard the cliché of “gotta kiss a lot of frogs to find a prince”, but that still means you’re out in the swamp, planting your lips on a bunch of amphibians. Unless you’re a MILF (Man, I Really Love Frogs), the shine is gonna wear off pretty quickly.

This is why I tell people that sometimes the best way to meet people is to just get lucky… and to understand what goes into making your own luck. Yes, meeting Mr., Ms. or Mx. Right is often a matter of luck. It’s the old saw of luck being the intersection of random chance and preparation, with a better understanding of what that preparation looks like and how to set it up so you don’t sandpaper your soul raw in the process.

The people who are the luckiest in general aren’t blessed by Loki or Tymora or they just happened to have caught Coyote on a good day. They’re the ones who put themselves in fortune’s path – living in such a way that makes serendipity more likely to happen. This way they’re in position to take full advantage when opportunities present themselves.

The easiest way to get lucky without going out and being on the dating market is simply to live your life, enjoy the activities you enjoy and otherwise have a good time in ways that bring you in contact with other, likeminded folks. You’re not looking for your perfect match, you’re just out doing the things you love and, in doing so, meeting people who also enjoy those things.

This may mean gardening clubs or amateur sports teams. It may mean taking conversational language classes or getting a pub quiz team together. Maybe it would involve political organizing or picking a charitable cause to champion. But by spending time doing the things you love and that feed your soul, with other folks who feel similarly, you increase the odds of meeting someone who would be right for you.

And the benefit of this approach is that it’s great for people like you, people who need time to warm up to folks and develop a connection first. Because you aren’t out there Dating – capital D – you don’t necessarily feel the same self-imposed pressure to speed through things. You can get to know people over time, build a connection to them and see how things grow. Someone may seem like they’d be a perfect match on paper, and you enjoy their company… but without that pressure to lock things down, you have the time to see whether the chemistry and compatibility is there or if they’re just someone who might make a good friend.

This is, after all, how most people tend to meet their partners. We very rarely start a relationship with a stranger shortly after meeting them; we tend to develop a connection over time. And since you’re not telling yourself that you need to be in a rush, you can take that time to see how things go. If it turns out they’re not right for you, then you aren’t out time that you might have spent elsewhere; they were part of what you were doing already. But if they are right for you, then you’ve had the most amazing bonus to living your life the way you like.

This is why we say that it’ll happen when you least expect it. Not making dating the forefront of your mind means that if and when it does happen, you’ll be pleasantly surprised.

If you take the pressure off yourself to get a particular result and simply live your life in ways that bring you in contact with people who share your interests in passions, you’ll have a much more enjoyable time. It won’t feel the way being On The Market does simply because… well, you’re not. You’re just out and about doing the things you love that just happen to make it more likely for serendipity to happen. And if it doesn’t happen – or in the way you expect – then you’re not out anything, because you still have the rewards of pursuing those passions and ambitions. It’s not quite win-win, but it’s certainly an outcome you’re already satisfied with.

So live your life in the way that brings you contentment and satisfaction, SSATY. Love knows where to find you when it’s time.

Good luck.

Please send your questions to Dr. NerdLove at his website (www.doctornerdlove.com/contact); or to his email, doc@doctornerdlove.com