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Many women sail through the menopause, but for others, the experience can be tough, physically and emotionally.To help ensure that your menopause is as smooth as possible, the Daily Mail has worked with Britain’s specialists to bring you the latest thinking on living with it, from hormone therapy to supplements, gadgets and exercises.On Saturday, we showed you what to eat to reduce your symptoms. Today, we look at how to maintain your sexual and mental wellbeing, so you can carry on feeling — and looking — sexy throughout this time.IT’S NOT YOUR FAULT YOU’VE LOST INTERESTFor many women, their middle years can mark a sharp drop in libido — though most are loath to talk about it. The good news is there is much you can do to help.Sex problems can start with the perimenopause — the four to ten years leading up to the menopause when ovulation stops.
During the menopause, many women will notice that their libido decreases (picture posed by models)During this time, common symptoms such as irritability, mood swings, anxiety and fatigue can combine with physical changes linked to the menopause to leave you feeling your sex life is a thing of the past.It’s not just the decline in oestrogen and progesterone that have an effect: your levels of testosterone (which women produce in smaller amounts than men), also fall, affecting sex drive, mood and energy.This is also a time when a woman’s confidence in her sexual attractiveness can falter, and there may be anxieties about children growing up and leaving home (or not leaving) and increasing commitments to aged parents.
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Our sense of sexuality is so subtle and emotionally linked that psychological factors certainly play a part. Sexual problems affect an estimated 20 to 40 per cent of women at this stage of their lives, so you are not alone if you’re having difficulties. (It is also worth pointing out that some women are not concerned about their lack of sex drive.)Many of the physical problems relating to a poor sex life are down to the drop in oestrogen. The hormone helps the body produce collagen, a protein that keeps tissues healthy and is needed for lubrication.Reduced oestrogen can affect sensation and the ability to orgasm, while the drop in natural lubrication can cause uncomfortable dryness and itching — around half of the menopausal women who have sex problems suffer from this, but many are too embarrassed to discuss it with a doctor, says Dr Jane Woyka, a London GP who sits on the advisory board of the British Menopause Society.
Sexual problems affect an estimated 20 to 40 per cent of women at this stage of their lives (picture posed by models)Reduced oestrogen means that vaginal tissue can thin, weaken and shrink, which can make sex uncomfortable, even painful.And at this time of life, many women simultaneously develop conditions such as incontinence, prolapse and recurrent urinary infections, which interfere with a healthy love life.Up to a third of women in their 50s are affected by these conditions, says Dr Tim Hillard, a consultant gynaecologist and specialist in uro-gynaecology at Poole Hospital NHS Foundation Trust, and lack of oestrogen can be the trigger.  This is also a time when a woman’s confidence in her sexual attractiveness can falter, and there may be anxieties about children growing up and leaving home. ‘Oestrogen levels help keep the vaginal skin and muscle supporting the pelvic floor strong and hold everything in place, but the loss of oestrogen can lead to bladder weakness and leakage of urine when you cough or sneeze, known as stress incontinence,’ he says.In extreme cases, this can lead to prolapse, where one or more of the pelvic organs drops into the vagina.‘At menopause, women are also more prone to recurrent urinary infections such as cystitis because the natural defence mechanisms are weakened by a lack of oestrogen.‘The weakness of the sphincter muscle is most commonly as a result of damage to the nerves in childbirth, but because the surrounding muscles and tissues are relatively strong when you’re young, the symptoms often don’t develop until the tissues get weaker around the menopause.’USE IT OR LOSE IT?It’s important to discuss any concerns with your GP. But one of the simplest solutions may be to have sex, as this ensures a regular supply of blood to the area, keeping tissues healthy, and functioning effectively.Avoiding sex can make things worse, says Dr Woyka. It’s the use it or lose it principle.
 Dr Woyka says that avoiding sex can often make dryness and irritation worse (picture posed by model)stratumc.com).There are also prescription-only face creams that contain oestrogen, though you will have to go privately to get these. Some over-the-counter preparations contain plant oestrogens, which are said to have a similar effect. These include Murad’s Intensive Age Diffusing Serum (£65, murad.co.uk and department stores) and Nurture Replenish day and night cream duo (£20.90, nurtureskincare.co.uk).Omega 3 oils may also help with dry hair and skin, so make sure you have oily fish twice a week or eat plenty of nuts and seeds. Taking the hormone in the form of a gel, patch or implant can help improve libido.However, there is no testosterone patch or gel specifically licensed for women, so your doctor will have to prescribe a male product on an ‘off label’ basis, meaning the doctor bears legal responsibility if anything were to go wrong.However, many GPs are reluctant to do so — partly because a flagging female sex drive is not considered to be a medical problem.There are also concerns about lack of information on potential long-term side-effects.Furthermore, very high doses of testosterone can cause acne, facial and body hair and enlargement of the clitoris.However, Professor John Studd of the London PMS and Menopause Clinic (and former professor of gynaecology at Imperial College London), is convinced that testosterone is safe for women.‘Ninety-three per cent of the menopausal women I prescribe HRT are also treated with a low dose of testosterone gel, in addition to other hormones, at one-tenth of the dose we give to men — and it makes a real difference,’ he says.You are more likely to get a testosterone prescription from private clinics — it will cost around £56 for a tube (100 daily doses).Alternatively, if you feel you could benefit from testosterone treatment, ask your GP about Livial, a form of HRT that appears to stimulate production of male hormones including testosterone.Side-effects, which affect less than one in ten women, can include irregular hair growth, breast tenderness, vaginal bleeding and spotting.VAGINAL MOISTURISERS: These are better than KY jelly, says Dr Heather Currie, a consultant gynaecologist and managing director of the information website menopausematters.co.uk.‘KY jelly is a short-acting lubricant designed for medical use; other brands last longer and are better suited for sexual activity,’ she says.Specifically formulated vaginal moisturisers (such as Replens, £10.99, and Sylk, £7.49) are available over the counter or on prescription.Another option is balance Activ Menopause (£11.99, gel and pessaries from pharmacies and balanceactiv.com), which contains a synthetic form of hyaluronic acid, a compound in the body that helps moisturise tissues.Canesintima Intimate Moisturiser (£12.99 for 50ml from pharmacies) is a new lubricating gel from the makers of Canestan. But note: lubricants won’t help with symptoms such as lack of muscle tone and genito-urinary problems.PELVIC FLOOR BOOSTERS: Special exercises can tighten the pelvic floor, improving incontinence symptoms and sexual function.
Special exercises can help strengthen the pelvic floor muscles, improving incontinence symptoms and sexual functionA recent study at the John Radcliffe Hospital in Oxford found that women who did the exercises reported a 70 per cent improvement in their stress incontinence.The greatest improvement was seen in women whose exercise regimens were supervised, rather than just doing it themselves.
Studies show that the greates improvement has been seen in women who have had their exercise regimes supervised (picture posed by model) The researchers found that once you’ve built up muscle tone, you don’t need to do the exercises as much to maintain it.Knowing how to do the exercises properly is crucial — if you’re not sure, ask your GP for referral to a specialist physiotherapist or nurse.Using a pelvic floor ‘exerciser’ may help. As Dr Jan Toledano, a senior doctor at the Marion Gluck Clinic in London, explains: ‘Pelvic floor exercises are extremely important, so any device that encourages women to work them — and also offers guidance on performing them correctly — is a good idea. However, because they won’t help vaginal problems caused by the menopause, I advise using a pelvic toner in conjunction with an oestrogen gel such as Vagifem.’ELVIE: From £55, elvie.com. An egg-shaped, sensor-packed device that’s inserted into the vagina. You clench your muscles around it in five-minute workouts designed to ‘lift and tone’ — multiple sensors measure the pressure and this information is relayed via Bluetooth to an app on your smartphone to offer real-time feedback on your technique.PELVICTONER: £31.99, pelvictoner.co.uk. A plastic, torpedo-shaped device, which you squeeze against to help strengthen the pelvic floor. This is available on the NHS through your GP.ARENT I TOO OLD TO HAVE A BABY?The simple answer is no, as you can still conceive while you’re going through the menopause. The official advice is that you need contraception for a year after your last period if you’re over 50 — it’s two years if you’re under 50.Many menopausal women wrongly stop using contraception once their periods become irregular, says Dr Helen Bickerstaff, a consultant gynaecologist and obstetrician at Guys and St Thomas’ NHS Foundation Trust.
It is still possible to conceive during the menopause, official advice states that you need contraception for a year after your last period if you’re over 50 — it’s two years if you’re under 50 (picture posed by model) ‘Certainly during times of irregular bleeding and hot flushes, a woman is probably not going to get pregnant as she’s not ovulating normally. However, out of the blue, she can go back into a cycle of a few months of regular ovulation and periods. All it takes is one normal egg at the right time.‘So women really do need contraception until they have fully completed the menopause.’And women who’ve previously been unable to conceive may suddenly become pregnant, says Dr Bickerstaff, who is also a senior lecturer in medical education at King’s College London. Fluctuating hormones may mean some ovulate for the very first time.‘It happened to my mum — she had my sister and me when she was 44 and 46 — having never had a period in her life because she had polycystic ovaries [cysts on the ovaries],’ she says.WILL THE PILL STILL WORK?You can continue taking the Pill, which contains oestrogen and progesterone, unless you’re a smoker or at high risk of stroke or cardiovascular disease.However, menopausal women often move onto progesterone-only forms of contraception, which ‘block’ periods by stopping ovulation. These contain progestogen, a synthetic form of progesterone.
Many menopausal women will revert to a progesterone-only form of contraception (picture posed by model) The advantage of progesterone-only contraception is that as well as preventing conception, it reduces bleeding, which is helpful for irregular, heavy or painful periods.The options include Norplant (a 40 mm flexible tube inserted under the skin of your upper arm where it emits progestogen), Cerazette (a pill) or a progestogen injection. This is usually given in the bottom — the most commonly used, Depo-Provera, is administered every 12 weeks (this can be done by your GP or practice nurse).Dr Bickerstaff recommends the Mirena coil for perimenopausal women. This is a small, T-shaped device that’s inserted into the womb where it releases progestogen.‘It’s more reliable as a contraceptive even than some forms of surgical sterilisation, such as clipping the fallopian tubes,’ she says.‘It can be fitted by your GP or gynaecologist and should last between three or five years (depending on which version you have), so can take you right through the perimenopause without you having to think about it.’An added advantage is that Mirena automatically provides the progesterone element of HRT, so if you want to take HRT, you need to be ‘topped up’ with oestrogen.The Pill and progesterone-only contraception can help ease menopausal symptoms such as irregular and heavy bleeding. However, contraceptives can have side-effects.A potential disadvantage of progesterone-only contraception is that you may need to come off it to find out if your periods have stopped and you’ve reached the menopause.Or you could ask your GP for a blood test for the follicle-stimulating hormone (FSH) — levels rise during the menopause. Doctors like to carry out two tests with a six- week gap as FSH levels can vary day to day.Many women wrongly think being on HRT will prevent pregnancy, says Dr Bickerstaff — it won’t.BANISH THOSE MOOD SWINGSThe menopause isn’t just a time of tumultuous physical changes, but emotional and psychological upheaval, too.‘Oestrogen has a direct effect on the brain and so the menopause is a common time for mood swings, irritability, anxiety, panic attacks, low mood, memory problems and depression to strike,’ says Dr Jane Woyka.‘Women talk about suddenly becoming tearful, irritable, tense, anxious and panicky.
The menopause can be a time of intense emotional and physical change and upheaval, some women have mentioned becoming tearful, irritable and tense (picture posed by model) 
bemindfulonline.comAdditional reporting: Michele O’Connor, Fiona Duffy and Amanda Cable. WHY DIDNT MY DOCTOR BELIEVE MY PANIC ATTACKS WERE LINKED TO THE MENOPAUSE? Psychotherapist Kim Harries, 51, lives in Tring, Hertfordshire, with her partner Mike Crow, a retired antiques expert, and her son, 13. She says:
Kim Harries (pictured) began suffering from panic attacks about 18 months after her periods stoppedAbout 18 months after my periods stopped, I began suffering from anxiety and panic attacks and developed a totally irrational phobia of driving.I’ve always loved driving — so much so that I’d treated myself to a new Mazda sports car — but I started to avoid getting into my car at all if I felt that I was having a bad day.Then, last November, I had to drive to a meeting in Cambridge and I was suddenly overwhelmed by a panic attack — I started worrying whether I was holding the steering wheel OK and froze with terror.As I fought to keep control of my senses and the car, I started to hyperventilate and felt physically sick. Using deep breathing methods, I forced myself to keep calm and pulled over.When I felt better, I continued my journey, but the last four miles took an hour because I was in such a terrible state. I’m normally logical, calm and totally in control, but I was terrified.The panic attacks and severe anxiety became so bad that, in December, I had to take four weeks off work. My GP signed me off — I asked her to put down ‘menopausal symptoms’, but she wrote ‘overall malaise’.She also refused to do a blood test for the menopause, insisting I was ‘over’ it because my periods had stopped more than a year earlier. She prescribed Prozac, though I begged for HRT. As a professional, I knew that a drop in oestrogen can lead to anxiety, panic and depression.But I was told my symptoms came six months too late for her to treat it as the menopause.I spent two weeks in bed, crying constantly and feeling too scared to face the world until the Prozac began to calm me.But I still couldn’t sleep as my mind was racing, which left me exhausted. I then started developing other menopausal symptoms. My hair thinned, my skin lost elasticity and my thigh and shoulder bones ached.I also suffered from hot sweats during the day, and became clumsy — in January, I tripped over a shoe and broke my right arm.I still suffer from a constant state of anxiety with frequent panic attacks. As a therapist and an intelligent, professional woman, I feel humiliated and ashamed that, despite my knowledge, I haven’t been able to prevent these overwhelming feelings.In America, there are menopause clinics where specialists conduct blood tests, bone scans and help to treat symptoms holistically, with massages and dietary advice.But I am still having to fight just to have a blood test to prove that it really is the menopause causing these extreme anxieties.  
Read more:
Menopause Matters, menopausal symptoms, remedies, advice
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advocaat

Dick Advocaat has been appointed as Sunderland manager on a deal until the end of the season.The 67-year-olds package will be incentivised with the target of Premier League survival.Advocaat told the clubs website: Sunderland is a big club and I am very much looking forward to the challenge ahead. We must now concentrate on Saturday as a priority and I cant wait to get started.
Dick Advocaat, pictured here in charge of PSV Eindhoven in 2012, has taken over at Sunderland
Gus Poyet was sacked by Sunderland with the club just one point above the relegation zone
Sunderland supporters turned on manager Poyet after their side were thrashed 4-0 by Aston Villa  Sunderlands last six permanent Premier League managers Manager Joined Left Games Won Drew Lost
Win % Gus Poyet 08/10/2013 16/03/2015 60 14 21 25     23.33 Paolo Di Canio 31/03/2013 22/09/2013 12 2 3 7     16.67 Martin ONeill 05/12/2011 30/03/2013 55 16 17 22     29.09 Steve Bruce 03/06/2009 30/11/2011 89 25 27 37  
28.09 Ricky Sbragia 04/12/2008 25/05/2009 23 5 6 12   21.74 Roy Keane 28/08/2006 04/12/2008 53 15 9 29   28.3 DICK ADVOCAAT FACTFILE  Teams managed: DSVP (1980-84), Holland (assistant manager, 1984-87), HFC Haarlem (1987-89), SVV (1989-1991), Holland (assistant manager, 1990-92), FC Dordrecht (1991-92), Holland (1992-94), PSV (1994-98), Rangers (1998-2002), Holland (2002-04), Borussia Monchengladbach (2004-05), United Arab Emirates (2005), South Korea (2005-06), Zenit St Petersburg (2006-09), Belgium (2009-10), AZ Alkmaar (2009-10), Russia (2010-12), PSV (2012-13), Serbia (2014), Sunderland (2015-)Honours: Eerste Divisie (SVV, 1989-90), Eredivisie (PSV, 1996-97), KNVB Cup (PSV, 1995-96), Scottish Premier League (Rangers, 1998-99, 1999-00), Scottish Cup (Rangers, 1998-99, 1999-00), Scottish League Cup (Rangers, 1998-99), Russian Premier League (Zenit, 2007), Russian Super Cup (Zenit, 2008), UEFA Cup (Zenit, 2007-08), UEFA Super Cup (Zenit, 2008) Chairman Ellis Short said: Dick has an incredible CV and vast experience of managing at the very highest level. We have one aim only now – to climb the table and everyone is fully focused on the task ahead of us. Advocaat could land up to £500,000 if the Black Cats – currently one point above the relegation zone – avoid the drop. He has brought with him Montenegrin coach Zeljko Petrovic, who was Avram Grants assistant at West Ham in 2010. Former Swansea and England Under 20 goalkeeping coach, Adrian Tucker, also joins Advocaats backroom staff. It is unlikely, however, that Advocaat will be considered as the permanent successor to Gus Poyet, who was sacked on Monday after 17 months at the Stadium of Light.Sportsmail understands that West Ham manager Sam Allardyce and Real Madrid assistant Paul Clement are at the top of the clubs shortlist to take charge beyond this season.Clement, in particular, fits the profile of coach who could work within the structure at the club, where sporting director Lee Congerton has control over transfers.Clement and Congerton know each other from their time at Chelsea and the Real No 2 is thought to be keen to try his hand as a manager back in England.Meanwhile, it is Congertons contacts book which has led to a deal with Advocaat.Former Chelsea sporting director Frank Arnesen – who worked with Advocaat at PSV Eindhoven and Congerton at Stamford Bridge and then Hamburg – recommended him for the role.Previous
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