For nigh onto 30 years, the North American Menopause Society has encouraged research into and disseminated information about all things menopause. It’s the hub of the wheel for healthcare professionals and individuals alike seeking the latest scientific information and objective advice about “the change.”
One presentation at this year’s annual meeting in October struck me as particularly apropos for MiddlesexMD readers—part refresher course; part new information. So I’d like to pass it along.
In a wide-ranging talk, Dr. Nick Panay, a gynecologist from Great Britain, explored current understanding of that most common and persistent problem of menopause: painful sex due to vaginal dryness. He reminded us that lots of women will suffer from it (about half of women at some point in life), and that many won’t mention it to their doctors. He encouraged healthcare workers to ask: “If you don’t ask, women often won’t volunteer the information.”
So far, so good, but ground that’s been covered.
Everyone likes sex better with good lubrication, he said, and women often expect their bodies to lubricate adequately, just like they did “before,” so when they inevitably don’t, it’s a real buzzkill for sex.
This state of affairs can be tackled in many ways—topical estrogen, Osphena, Intrarosa, and the good old stand-by, moisturizers and lubricants. According to Dr. Panay, moisturizers and lubes can provide relief from vaginal dryness, but they don’t address the underlying cause, which is loss of estrogen. Only estrogen can do that.
Turns out, however, that a couple additional considerations might affect how your body reacts to a specific moisturizer and/or lubricant, depending on its ingredients. In this report, Dr. Panay mentions three physical characteristics of the vagina that might be altered by components in what we put there.
Ideally, says Dr. Panay, the lube/moisturizer you use should be as close to vaginal mucosa as possible—a product that is “optimally balanced in terms of both osmolality and pH and is physiologically most similar to natural vaginal secretions.”
Trouble is that the ingredients in a moisturizer or lubricant aren’t always listed on the label and identifying those with correct osmolality and pH levels is fairly impossible for the average user, especially since a product with a good pH level might have bad osmolality numbers. Dr. Panay shared the results for several dozen products available worldwide, and we were happy to see that YES VM, a moisturizer, and YES WB, a lubricant, both scored very well in the testing (we shouldn’t be too surprised, since they’re both very popular in our shop).
So what’s the practical application for all of this new data? For us at MiddlesexMD, we’ve got some new criteria for vetting and recommending products from our shop (sadly, Dr. Panay’s tests couldn’t include every product currently available). We hope that makers of moisturizers and lubricants will take these new findings into account in their formulations, and we can now ask for data on osmolality in addition to pH levels when we evaluate products.
For you, keep in mind that lubes and moisturizers are the first line of attack in making sex comfortable (or possible) and in keeping vaginal tissue flexible and moisturized. According to Dr. Panay, this is true even if you use topical estrogen or another drug, such as Osphena or Intrarosa. Choose your products carefully, looking for high-quality products that are free of glycol, parabens, and other additives.
Pay attention to any increase in vaginal irritation or infections. Your lubricant or moisturizer could be contributing. Don't give up on lubes or moisturizers, though: Try another product or formulation that’s a better match for your pH and is providing the right amount of moisture to your tissues.
There are many reasons women may have pain with sex, so I can’t be certain of the specific cause for your wife. A pelvic examination by her health care provider is needed to determine the cause and therefore the proper treatment.
That being said, the most common cause of painful intercourse in perimenopause (the phase before menopause) or post-menopause (beyond the year after the last menstrual period that marks menopause) is due to the reduction or loss of estrogen and the atrophy or dryness that result.
Using a vaginal moisturizer regularly, two to three times a week, is a great place to start; if the atrophy is not advanced, restoring moisture to the tissues may help. Using a silicone lubricant with sex may help, too. I recommend Pink, which is very slippery and, because it has Vitamin E and aloe, it’s soothing, too. If there’s been some vaginal narrowing in the process of atrophy, vaginal dilators can be helpful, too, by gently stretching the vaginal tissues.
I hope this is helpful, and encourage you and your wife to pursue a medical evaluation to enhance her chances of regaining comfort! There may be a physical issue that needs addressing, and there are also prescription-only products available to address her symptoms. For a practitioner focusing on menopause care, I recommend the North American Menopause Society’s practitioner finder.
You say you’re four years past menopause, and in addition to hot flashes and other symptoms, you have dryness and have had vaginal atrophy—a decrease in the size of your vaginal opening. This is a classic symptom of genitourinary syndrome of menopause (GSM, earlier called vulvovaginal atrophy). Without estrogen, the vaginal tissues become thin and fragile, and the vagina can shorten and narrow.
Vaginal moisturizers, which you say you’re using, are of some benefit. They’re better at prevention, though, started during perimenopause or early in menopause; once atrophy is advanced, they’re less helpful and may be irritating, as you’ve experienced.
The most likely effective treatment is localized estrogens (cream, ring, or tablet) or something like Osphena (oral and non-estrogen) or Intrarosa. You say you like to avoid chemicals, and I understand that; estrogen is a natural chemical, and the local application is to replace what your body used to produce naturally in the way that has the fewest side effects. Osphena and Intrarosa work like a hormone, even though they aren’t one. These are all prescription therapies, and a necessary component of your plan to counter the effects of vulvovaginal atrophy, which is chronic and progressive.
Once the tissues are healthier, you may need to use vaginal dilators to regain increased “capacity” (patency, in medical terms) of the vagina.
Whenever there is pain involved, that problem needs to be addressed first; once you’ve achieved physical comfort, you may find a sex therapist helpful if issues remain, as your gynecologist suggested. In the meantime, no one should blame you for not wanting to have painful sex!
A number of the things you say are very familiar to me: you’ve had plenty of natural lubrication and you’ve never had issues with intercourse. The unfortunate reality is that menopause changes the game, more dramatically for some of us than others. What was true for the younger you is no longer the case (ask me about menopausal weight gain!). But! I know how important intimacy is to relationships, and if you’re willing to make the effort, it’s almost always possible to regain function and comfort again.
Six weeks before Christmas, and we all know the drill. We muddle; we fret; we scour, until… we find that perfect, thoughtful, useful, attractive gift for those special people in our lives who just happen to have everything. Does it feel like an exercise in futility
While you’re scrounging around the Internet labyrinth, you might include a quick spin through our MiddlesexMD shop. We’ve already done the searching and the testing to suss out the highest-quality products that you (and we) can trust. And you won’t find a selection remotely similar in the mall. Guaranteed.
While you might not want to give your mother a vibrator for Christmas, other products might tick all the boxes for a thoughtful, attractive, useful gift.
For the special women in your life—mother, daughters, friends: Knowledge. Navigating the rocky shoals of menopause is no picnic. Simply understanding why and how our bodies are changing and knowing what to expect can sometimes make a huge difference in how we weather the storm (listen to our recent podcast on this subject here). For example, understanding why we could suddenly gain weight and have so much trouble losing it can be an epiphany. And that’s not to mention the challenges of maintaining a vital sex life.
You might consider these books for a nearly menopausal friend, sister, or daughter:
If you like our website and find this blog helpful, you might like Yes, You Can: Dr. Barb’s Recipe for Lifelong Intimacy. It’s a collection of the common-sense explanations and explorations of health and sexuality that’s made MiddlesexMD one of the most popular blogs for the over-50 crowd. I share my decades of experience in treating women’s menopausal and sexual issues in, I hope, a sisterly style.
The practice of mindfulness can be an important factor in stress relief, overall well-being, and tangentially, a vital sex life. We think it’s so important that we’re happy to include The Miracle of Mindfulness, by Thich Nhat Hanh. This is a classic in the canon of books on meditation, spirituality, and mindfulness. It might be a thoughtful counterpoint to the feeding frenzy of the holidays.
Better Than I Ever Expected by Joan Price. We’re a fan of Joan's straightforward yet lighthearted style. The book is a good overview of the multi-hued issues that accompanies menopause, especially as it relates to sexuality. This may be a good choice for women who want to warm a tepid relationship or for those embarking on a new romance.
We’ll step out on a limb here and recommend She Comes First: The Thinking Man’s Guide to Pleasuring a Woman by Ian Kerner as a gift for a receptive lover. Dr. Kerner is a clinical sexologist who explores the anatomy and psychology of sex. In this book, he does not overlook his personal struggle with sexual dysfunction. Described as “straightforward, intimate, and exuberant,” this book is highly recommended by many experts and doctors.
Everyone loves a good cookbook, and The New Intercourses: An Aphrodisiacs Cookbook is one we love. This book covers it all, exploring the history of aphrodisiacs, pairing recipes for decadent foods with the time of day, the season, and the stage of a relationship, all presented with lush photography. It even includes recipes for massage oils and bath salts and oils. This book is a delight for all the senses.
Speaking of sensual delights. Feeding the mind is fine, but a gift that pleasures the senses is what the holidays are all about. Any of these would be lovely choices for a romantic partner or a female friend.
The Lelo massage candle is a unique gift for your intimate partner or a sweet encouragement for your menopausal bestie. Made with a rich soy, almond kernel oil, and shea butter, the candle melts into a silky massage oil. It also comes in alluring, grownup scents, such as black pepper and pomegranate or snow pear and cedarwood.
The Sliquid O Gel is a racier gift for your Sex In the City girlfriend. Both lube and warming oil, O gel takes stimulation to the next level. With peppermint oil and menthol, O gel soothes and warms. Not for everyone, but exactly right for a more experimental someone.
For your romantic partner. We’ve gathered some unique products to share with your one-and-only. Slip them in the stocking or on the pillow along with a rose, a bottle of bubbly, your favorite sound track or all of the above.
Our Stocking Stuffer kit may be as much about you as it is about him, but we’re thinking he’ll be happy that you’re into making sex good for both of you. The kit contains the Jolie vibrator—a small but perky little number that you can both play with, a bottle of Yes water-based lubricant, and a small box of romantic, magnetic poetry. With any magnetic surface, you could create your own Shakespeare in Love boudoir. Express sentiments that take you beyond the day-to-day.
Romantic Vows for Affectionate Lovers gives you a playful way to express your feelings. Choose from 72 cards that seduce, promise, and describe. Hide them in his sock drawer or take turns surprising each other. It’s a low-pressure, flirtatious way to keep the flame alive.
One of our newest offerings, the Fin vibrator is a powerhouse in a teensy package. Made “by women for women” at Dame Products, Fin is comfy, unobtrusive, and intuitive. It’s also good for couple play. All Dame Products, including this one, come with an engaging instruction manual to get the most out of your toy.Color him chocolate? And why not? You can do just that with our Lover’s Body Paint. A 2-ounce bottle of rich chocolate or caramel (or both?) and a soft brush and your lover becomes your own edible canvas. Or vice versa. Messy, silly, and surprising. The perfect stocking stuffer.
A while ago, I recommended the Mediterranean diet as part of a healthy weight-loss regimen for that post-menopausal muffin top. But it’s so much more than a “diet” and has so many proven and critically important health benefits that I decided to circle back and dig a little deeper into the Mediterranean diet and the lifestyle that surrounds it.
It would be hard to pin down one way of eating that adequately sums up the Mediterranean region. People in southern Spain eat differently from those in Morocco or Greece, yet researchers have identified several commonalities of the region that produces some of the healthiest and longest-lived people on the planet. Case in point: two of the five “Blue Zones”—places with the highest concentration of centenarians in the world—are located in the Mediterranean, including Sardinia, where men live as long as women. (The ratio of male to female centenarians is 1:1.)
Granted, a long and healthy life is the result of many factors beyond diet, not the least of which is the genes you were born with. Nonetheless, the way you eat is critical to your health, and unlike your genes, is something you can control. (Along with several other contributors to longevity. More on that below.)
Despite its broad and diverse geography, several characteristics are common to the Mediterranean diet.
That’s it. Simple and delicious. Notice that this approach to diet isn’t vegetarian or vegan. It isn’t gluten- or dairy-free. It isn’t a fad or a flash-in-the-pan. These traditional diets have been around for a long time. Numerous studies confirm that, in addition to weight loss, the Mediterranean diet has powerful protective factors from cardiac problems and some types of cancer.
According to literature from the Mayo Clinic, the Mediterranean diet is “associated with a reduced incidence of cancer, and Parkinson's and Alzheimer's diseases. Women who eat a Mediterranean diet supplemented with extra-virgin olive oil and mixed nuts may have a reduced risk of breast cancer. For these reasons, most if not all major scientific organizations encourage healthy adults to adapt a style of eating like that of the Mediterranean diet for prevention of major chronic diseases.”
How’s that for an unambiguous statement from a leading medical organization?
While diet alone is an important contributor to health and longevity, it sure isn’t the only one. This is because those long-lived individuals in the Mediterranean and other Blue Zones are embedded within communities and cultures that support both mental and physical good health. These are cultures that tend to engage in activities that naturally involve movement: gardening, walking, housework. They are surrounded by a network of kin and friends that provides a sense of purpose, support, and well-being. They know how to de-stress, maybe with a nap or a drink with friends. And they disproportionately belong to faith communities.
These elements, of which diet is a part, have been around for a long time. These cultures have a deep wisdom to impart to the rest of us born within more modern and less mature cultures. While we won’t be able to replicate life in a Blue Zone, we can look to them for guidance.
Maybe the easiest way to start is with diet. But a lifestyle of commitment, community, faith, and natural movement is a decent goal to shoot for as well.
To help motivate you, here is a Mediterranean-inspired recipe (bonus! appropriate for the season) from the lovely Intercourses cookbook, which explores the playful nature of sex and the aphrodisiac qualities of food.
½ cup walnuts, coarsely chopped
1 pound peeled pumpkin or butternut squash, cut into 1-inch cubes
1 Delicious or other sweet apple, peeled, cored, and cut into slices
2 to 2 ½ cups chicken stock
2 teaspoons finely grated fresh ginger
¼ cup heavy cream
Salt and pepper to taste
Devon or clotted cream
Madeira or amontillado sherry
This easy-to-make soup will get you feeling very cozy on a brisk autumn evening. The recipe calls for fresh pumpkin or squash; if you prefer, you may substitute a pound of canned pumpkin or frozen butternut squash, but in that case limit the simmering time to 7 minutes.
Yields 2 or 3 servings
Preheat the oven to 400 degrees. Spread the walnuts on a rimmed baking sheet and toast until lightly browned, about 7 minutes. Set aside.
Place the pumpkin and apples in a large saucepan and add enough stock to cover. Stir in the ginger and bring to a boil over high heat. Reduce the heat to low and simmer until the pumpkin is tender, about 30 minutes.
Use an immersion blender to puree the soup. Or, working in batches if necessary, transfer the soup to a blender and puree. (If you’re using an especially powerful blender, definitely work in small batches, as the steam released by too much hot soup may cause the blender’s lid to blow off!) Return the pureed soup to the saucepan and add the cream in a thin stream, whisking as you do so. Add the salt and pepper and stir.
Spoon a dollop of Devon cream into each soup bowl, and drizzle 1 or 2 teaspoons of Madeira on top. Pour the soup into the bowls and garnish each with some toasted walnuts.
You say your wife has lichen sclerosis and uses Estring, a ring placed in the vagina to provide localized hormones; she has difficulty doing Kegel exercises correctly.
The Intensity is very effective at contracting the pelvic floor muscles, which is does with electrical stimulation through specially designed electrodes. Contracting the muscles builds muscle tone, and it sounds like you and she are aware of the benefits of pelvic floor strength: keeping organs in their places, preventing incontinence, and strengthening orgasm.
The lichen sclerosis should not be a limitation in using the Intensity. Because the electrical stimulation works best if the Intensity is expanded for full contact with the walls of the vagina, it would work best if she slips the Estring ring out before using the Intensity, and reinserts it after. Otherwise the ring will prevent full contact and limit the effectiveness of Intensity use.
I hope this is helpful!
One of the unexpected benefits of producing a podcast (The Fullness of Midlife) is getting to talk to people who expand my thinking. I’d previously gotten this benefit from my book group—members of which selected reading I might not have naturally gravitated toward. With the podcast interviews, I can explore connections and intersections that may not be obvious on a printed page.
A recent example is my conversation with Druscilla French. She’s a cultural mythologist, not a line of work I ordinarily run across in my medical circles. But what we talked about—the stories we learn or adopt and how they influence what we think is possible—seemed especially appropriate to thinking about who we are as women at midlife. After our conversation, Druscilla sent along her notes from a lecture, which she agreed we could share here.
It may be that you’ve arrived at a point of introspection. Maybe this is your first autumn with an empty nest. Perhaps you’re assessing where you are with your partner now. You might be one of the disciplined who do an annual assessment through the holidays. Whatever your situation, you may find what follows helpful—and perhaps even fuel for discussion with your partner—or your book club!
I love stories. I majored in English. I have a Masters in Film and Television. My PhD is in Mythology. I have always been passionate about stories, but I didn’t really understand their power until I was in my forties.
My earliest love affair with a story was with Winnie the Pooh. My Disney princess was Cinderella. I have also fallen hard for Heidi, Nancy Drew, Scout Finch, Hermione Granger, Harriet Vane, and Idgie Threadgoode. In films I loved Dorothy in The Wizard of Oz. I loved Vanessa Redgrave as Guinevere in Camelot and as Julia in Pentimento; Audrey Hepburn in Charade but not Breakfast at Tiffany’s; Faye Dunaway and Renee Russo in The Thomas Crown Affair; Jessica Tandy in all her film incarnations; Whoopee Goldberg as Celie in The Color Purple and Terry in Jumping Jack Flash. I loved Jane Fonda after she grew up and Bette Midler and Lily Tomlin in pretty much anything.
In music, I’ve loved Joan Baez, Linda Ronstadt, Barbra Streisand, Janis Joplin, and Bette Midler, always. “From a Distance” makes me cry, every time.
Here’s who I never wanted to be: Doris Day, Sandra Dee, Annette Funicello (or any of the Mouseketeer girls), Scarlett O’Hara, Snow White, June Cleaver, Marilyn Monroe, Madonna, or Lady Gaga; nuns, brides, or secretaries.
What does all that tell you about me? A great deal, I suspect. It was a long journey from Winnie the Pooh to Idgie.
But this isn’t about me. It’s about you. It’s about personal mythologies.
People cannot tolerate living without a myth. Neither can nations or planets, religions, families or tribes. Yet, this is precisely what we are seeing play out here. Some are clinging to the old mythologies, resisting the notion that evolution and change are inevitable. Others have relinquished the old stories, but are struggling with the existential angst of not having a mythic container in which to live. Having let go of one trapeze, we are all in that terrifying time before grabbing on to the next.
All mythologies are illusions. They blind us to truths outside our perspective. However, living without one is so anxiety-producing that we cannot function at our highest and best.
To live without a mythology is to be in a state of anxiety and fear. Life is pervaded by the feeling that life has no meaning, individually we have no purpose, and there is no way of knowing what is going to happen next. Fear and anxiety are so uncomfortable that some turn these emotions into anger. Anger gives us the illusion of power, as we see in the memorable Network line: “I’m mad as hell and I am not going to take it anymore.”
With some exploration, we can determine what stories each of us has in her (or his) personal mythology. Get out your journal or a legal pad, and think about the characters and stories that you collected as raw material for your personal mythology.
When you’ve identified the characters and the stories, review what you’ve uncovered:
The next step is to examine the path you’ve taken in comparison to the stories you’ve identified. Are there parallels? Has your story diverged from the plotline you’d learned or expected? Are there points at which you’ve given away your power?
Do you have a current story? You may find, as I do, that it’s challenging to find stories in our culture that we’re interested in occupying. We’re in a time of cultural change, and many of the archetypal patterns reinforce youth or patriarchy.
If you’re uncertain about your current story, what stories engaged you this year? How does it compare to the stories of your youth? How does it compare with your earlier ones? Is this a story you can actually live in and manifest? Is it a remnant of what called to you earlier? Would it work better for you to have a new story, or is your current story serving your highest good?
We need stories, because we can’t tolerate the notion that we have no purpose and no destination. When we’re confident in our stories, we can say, “This is who I am. This is what I’m about.” It’s a way to keep asking, “What else is possible for me?” It takes courage and persistence, and it lets us live our lives as though they matter—because they do.
You say you’re looking for clitoral stimulation, and options you’ve tried are either too intense or have too small a surface--or both. My personal favorite and a top seller for MiddlesexMD is the Siri2, which is rechargeable. It has patterns as low as a soft flutter but a range wide enough for most midlife women. (I’ll admit I got mine before Lelo added the option to sync to the beat of nearby music.) A less expensive option is the Kiri, which is battery operated but still plenty powerful. It has 16 different speeds and six patterns.
Both of these options are shaped specifically for clitoral stimulation, with broad curved surfaces that I suspect you and your partner will find more satisfying than the shape you described.
We were disappointed to see Neogyn discontinued, since it filled a very specific niche in vulvar care--addressing itchy or uncomfortable vulvar tissue. We're recommending PrevaLeaf Soothe Natural Vaginal Soothing Cream, which has natural ingredients and is pH-balanced. It's formulated to absorb rapidly for fast relief.
The MiddlesexMD team is on the lookout for additional options; let us know if you find something that works well for you.
Relizen is a plant-based treatment for hot flashes and night sweats that has a solid clinical track record. What’s more, it doesn’t have one of the major drawbacks of the soy products we discussed a while back—phytoestrogens. These are the botanical imitators of estrogen that have received mixed reviews in scientific studies—some suggesting that they act too much like estrogen in the body and some suggesting that they actually work to protect against the effects of estrogen.
Relizen, on the other hand, has no estrogenic effects. It is made from the pollen of flowers that grow in southern Sweden. Very poetic, I know. It was developed by a Swedish doctor who also happens to be a biologist and a beekeeper and who apparently was a close observers of his bees’ collection habits.
I know what you’re thinking: Pollen=allergies! But our Swedish doctor invented a process that removes the allergenic husk from pollen and processes only the cytoplasm—its nutrient-rich inner core. And voilá!—a totally natural and non-estrogenic product that just happens to work very well to relieve vasomotor symptoms (VMS) in menopausal women.
Unlike a lot of botanicals, Relizen has been clinically tested with results published in peer-reviewed journals such as Climacteric, and Menopause. In these studies, Relizen significantly reduced hot flashes without raising hormone levels after the first month of use compared to a placebo.
Additionally, after three months of use (you have to be patient here), up to two-thirds of the 400 women surveyed reported improved quality of life, not only due to a reduction in frequency and intensity of hot flashes and night sweats, but also because of a reduction in irritability and fatigue.
Aside from these studies of efficacy, the big advantage for women who want to stay away from anything with estrogenic qualities or women who are taking tamoxifen is that Relizen is safe. According to statements by Dr. Steven Goldstein, professor of OG/GYN at New York University, at the 2014 North America Menopause Society meeting, “Tamoxifen creates some of the worst hot flashes we will ever see.” Yet, after reviewing the clinical results, Dr. Goldstein feels that Relizen is safe for tamoxifen patients.
“It is the only nonpharmacologic product that I have ever been aware of that has a double-blind, randomized, placebo-controlled, parallel study showing that it reduces vasomotor symptoms and improves quality of life in menopausal women,” he added.
In my own clinical experience, several patients have responded well to Relizen, and like Dr. Goldstein, I have no concern about estrogenic interactions.
Relizen is taken as two tablets daily, and it might take up to three months to take effect. It’s been on the market for 15 years in Europe with over one million users, and it is one of the best-selling menopause products in France. While it can only be ordered online, and it isn’t inexpensive, Relizen may be worth a try for women who’ve tried everything else or for those who want to avoid drugs and hormones.