April 02, 2018

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anatomy ›   comfort ›   intimacy ›   pelvic tone ›  


Q: Does long-term sitting contribute to pelvic muscle spasms? What can help?

You say you’re using estrogen therapy, have sufficient lubrication, but are experiencing pelvic muscle spasms that cause you some discomfort during sex. You’re wondering whether being sedentary contributes to the problem, and whether a vibrator, which your doctor recommended, may help.

VibratorsIt’s unlikely that sitting too much would contribute to the muscle spasms (although as a doc, I need to recommend more physical activity). Unfortunately, most of the time we don’t have a good explanation as to the cause of muscle spasms. A vibrator works by increasing (through stimulation) blood supply to surrounding tissues, which, in turn, promotes vaginal health. If you choose a vibrator, make sure it’s one you can use internally, not just externally on the clitoris.

The other tool that’s often helpful with muscle spasms is a set of vaginal dilators. These are designed to provide a gentle stretch to pelvic floor muscles to reduce spasm.

I hope this is helpful! Part of the solution is to be confident you can address the issue.

February 15, 2018

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comfort ›   health care ›  


Q: Could my painful sex be related to varicose veins?

You asked. Dr. Barb answered.You describe your experience as “incredible pressure and pain,” and “deep aching pain.” You also said that you’ve had some varicose veins in your legs and have had some removed. Your research led you to vulvar varicosities, which does sound like a possible answer. These are varicose veins in the vulva, which are not all that common but do occur (often during pregnancy).

There are two options I’d like you to consider: The first is a good pelvic floor physical therapist. She or he can assess structurally whether there is evidence of a source for your pain. A great therapist can work magic! Really, they can.

The second option is a vein specialist. They can do an ultrasound assessment of vein function, even in the vulva, and try to help understand if that is what might be causing your discomfort.

Good luck on your journey! 

February 08, 2018

2 comments

comfort ›   intimacy ›   vaginal health ›  


Q: Can I have sex again? It’s been a few decades...

Sounds like you’ve been doing a number of the right things: You’ve been using dilators, a vibrator, lubricant, and vaginal moisturizer. It sounds like you’re at a point where localized estrogen, Osphena,  or Intrarosa would be helpful for you to achieve your desired outcome.

You asked. Dr. Barb answered.Any of these prescription drugs will provide elasticity, a critical factor for getting the “stretch” needed with the dilators. Take your dilators in to your health care provider and have this conversation, too. He or she can help you determine whether you can get further capacity with the methods you’re using or whether, as I suspect, you need to take the next step and add a prescription to your routine to restore health to the vaginal tissues.

It’s hard to get to the final goal without that option--and that final goal is definitely one worth working for! Good luck.

January 15, 2018

13 comments

about middlesexmd ›   comfort ›   intimacy ›  


Dilators: A Simple and Effective Stretch

Even though vaginal dilators have been around for decades, they still elicit lots of attention and a few quizzical looks even from healthcare professionals whenever we display our wares at medical conferences. My patients sometimes have questions, too, and we get phoned-in and emailed questions here at MiddlesexMD.

Dilators are one of the most straightforward medical devices you’ll run across. They are a set of tubes that gradually increase in diameter from about a half-inch to about an inch and a half. They are usually made of high-quality plastic, but may also be made of silicone, which gives them a softer, more flesh-like quality. Both types are washable with soap and water. Dilators are used to increase vaginal “patency,”—its capacity and ability to accommodate the things that vaginas are made to do, like a speculum, a baby, a penis—some pretty important stuff, in other words.

Dilators are used to:

  • Prevent scar tissue from forming after some cancers or pelvic radiation therapy.
  • Increase vaginal capacity and length after certain procedures, such as a total hysterectomy.
  • Maintain vaginal capacity during times when sex isn’t an option for whatever reason.
  • Improve vaginal capacity after a long time without sex (remember the old use it or lose it adage).
  • Help to address vaginal shortening and tightening due to hormonal changes of menopause.
  • Treat conditions, such as vaginismus, that make penetration difficult.

Since some vaginal conditions might require additional treatment, such as localized estrogen or muscle relaxants, you should always discuss any vaginal pain or change in your ability to have sex with your doctor, as well as how you might benefit from using dilators. From there, if it’s simply a matter of conditioning or maintenance, our shop has a selection of high-quality plastic and silicone dilators.

I recommend any of these sets. Choose the features and sizes that appeal to you. The first set that we found and offered remains a favorite. It’s available with five or seven dilators, depending on your starting point, and the straight, solid cylinders are easy to handle and clean.

The silicone kit is firm yet flexible with a softer touch. (Bright colors don’t hurt, either.) Be aware that silicone lubes will degrade the surface of these dilators, so use them only with water-based lubricants.

The Amielle kit is our high-quality, good-value choice. This set of five dilators is made of medical-grade plastic and includes a detachable handle that might make insertion easier.

Increasing vaginal capacity takes patience—often several months. For maintenance, you may need to use dilators regularly until you’re having sex regularly. The goal is to accommodate your partner’s penis (or your doctor’s speculum) comfortably and without pain. It’s a worthy goal, so accept that you’re in it for the long haul.

To use dilators:

  • Start with a warm bath to soften tissues and relax your pelvic floor muscles (along with everything else).
  • Find a comfortable and private place and lie down on your back, legs bent at a 45-degree angle and shoulder-width apart.
  • Consciously relax all your muscles, from head to toe. Do a mental scan for areas of tension around your eyes, brows, or anywhere else. Focus on breathing in; breathing out.
  • Begin with the smallest dilator and slather it with high-quality, water-based lubricant. (Not petroleum jelly or any kind of oil.) Generously lube your vaginal entrance as well.
  • Gently insert the dilator until you meet resistance. Pause. Breathe. Practice kegel exercises. Insert it a little farther if you can do this without discomfort. The dilator should fit snugly but without pain.
  • Keep it in place for twenty or thirty minutes. Watch TV or listen to a podcast or your playlist. Practice kegels.
  • You can try rotating it in place or moving it in a circular motion around the vaginal entrance or gently moving it in and out.
  • Clean with soap and water. Towel dry.
  • Move to the next size when you can comfortably insert the smaller one.
  • Do this 3-4 times per week or every other day.

You may bleed a little at first. This is normal. But if you soak a sanitary napkin or experience frequent bleeding, this is not normal. Stop using the dilator and call your doctor.

I like dilators because they’re both simple and effective. Granted, taking a pill is easier, but there are no pills that treat vaginal patency as such. If you stick to the regimen, dilators are very effective in both reconditioning the vagina and in maintaining elasticity during fallow sexual periods.

 

December 07, 2017

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about middlesexmd ›   comfort ›  


News from NAMS: The Latest on Lubes and Moisturizers

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.

  • pH balance. A healthy vagina is slightly acidic with a pH value between 3.8 and 4.5. Ideally, whatever lubricant or moisturizer you use should be close to those values to retain the vagina’s protective bacterial balance.
  • Osmolality. This is a fancy concept that refers to the amount of particles dissolved in a liquid. High osmolality has a lot of “stuff;” low osmolality doesn’t. The way this works in the vagina is that, ideally, equilibrium is reached between vaginal cells and the moisturizer or lube, depending on its osmolality. When the osmolality is off-kilter, it either draws water from vaginal cells or over-moisturizes them, either of which could cause changes in the vagina. In a test of several products on slugs, for example (yes, like you see pictured below), which as we know are all about moisture and mucus, products that were hyper-osmolalic (high levels of particles) irritated the slugs a lot.
  • Additives. Ingredients like glycols, parabens, and preservatives, which are found in some products can also irritate the vaginal lining, kill good bacteria, and increase susceptibility to infection.

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.”

slug like those used for testingTrouble 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.

October 26, 2017

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comfort ›   conditions ›   intimacy ›  


Q: What size dilator should be my goal?

I wish there were an exact “science of measurement” that would answer your question definitively. The vagina is typically elastic--especially when we’re younger--and will stretch to accommodate any (or nearly any) size required, but there can be male/female matches that are outside of that range.

You asked. Dr. Barb answered.As we get older, our vaginas become less distensible and less elastic. The tissue itself becomes less elastic as we lose estrogen, and we lose the “pleating” we had when we were younger (I’ve used the analogy of going from a pleated skirt to a pencil skirt). Dilators work by gently and gradually stretching the vaginal walls, making them open enough (called patency) to allow for comfortable intercourse.

Because of the variations in tissue elasticity, atrophy, a woman’s anatomy, and her partner’s anatomy, the goals are comfort and pleasure, not a specific dimension. Dilators come in sets of graduated sizes, so a user can move from one to the next-larger as she gains comfort with each. Some women will progress through the entire range of sizes; others will be satisfied before that.

We offer a variety of dilators, because women’s preferences vary. Our most popular, the Amielle kit, includes five sizes and a removable handle that provides more length for maneuvering. For those who prefer a solid dilator, we offer a six-inch-long option in a set of five or a set of seven, again depending on need. And for some women, the texture of silicone and its ability to be warmed makes the Sinclair Institute set of five their preference.

I hope this is helpful! I’ve very happy to hear that you’re still tending to your sexual health.

 

 

September 11, 2017

16 comments

comfort ›   hormones ›  


Q: Is there a “natural” replacement for Premarin?

In a sense, the most “natural” replacement for lost estrogen is estrogen, which is a prescription product (like Premarin or Estrace vaginal cream, Estring, Vagifem, or the non-estrogen Osphena).

You asked. Dr. Barb answered.If, for a number of reasons, you prefer not to take that path, the next-best option is to maintain vaginal tissues by using a moisturizer regularly, two to three times a week. Moisturizers are designed to bring more moisture--no surprise--into the vagina to prevent the progressive dryness that occurs in menopause with the absence of estrogen.

Both Emerita and Prevaleaf Oasis are natural vaginal moisturizers.

Shop Comfort and Vaginal Health Products

One more option might be an oral nutritional supplement, Stronvivo, which some research shows improves vaginal moisture. It does this by improving blood flow, and that circulation also supports tissue health.

 

 

September 08, 2017

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arousal ›   comfort ›  


Q: What can I do about my husband’s and my mismatched sex drive?

Oh, I feel for you. You say you have pain (and no doubt other symptoms—like fatigue and depression) from lupus, fibromyalgia, and Sjogren’s syndrome. You see your lack of interest in sex becoming a larger problem in your marriage as the difference between your sex drive and your husband’s increases.

The first order of business is to find a health care provider with whom you can discuss this aspect of your health. The pain you mention may be generalized pain from the autoimmune conditions you have, or it may be pain with intercourse. Painful intercourse is nearly always a treatable condition, so addressing that if you experience it is critical.

You asked. Dr. Barb answered.The harder issue is the “desire discrepancy” you describe in your marriage. While the situation is not uncommon, your additional health issues add a degree of difficulty. Assuming any issues with painful sex have been addressed, there are some medications that can be helpful for low libido: Addyi, testosterone, and Wellbutrin, to name a few. Your health care provider can help you understand if any of these can be an option for you depending on your health history and other medications you’re taking.

For more about low libido, you can read this blog post on the emotional component and this one that includes an overview of the condition and common causes. It could be helpful to read these to have some terminology in mind when you meet with your health care provider.

The situation you describe might best be addressed with a (sex) therapistperhaps not a dedicated sex therapist but one who has expertise in health-related relationship concerns. (Here are two blog posts on sex therapy: one I hoped would demystify it and one that explains how it works.) Your health care provider is likely to be able to direct you to someone with experience to assist you and your husband as you navigate this significant challenge.

Best of luck in reaching some common ground! 

 

September 05, 2017

0 comments

arousal ›   comfort ›   hormones ›  


Q: Is there an arousal product that's not irritating?

You say that your wife suffers from lichen sclerosus, a condition that creates skin tissue that is thinner than usual (and is a higher risk for postmenopausal women). Warming oils and lubricants, unfortunately, create discomfort rather than arousal for her. I'm not aware of an option in that category that would work for her, since the ingredients that make them effective--usually something minty or peppery--will almost certainly cause an adverse reaction.

Plain lubricants won't cause that reaction; those we include in our product collection should be well-tolerated by lichen sclerosus patients.

There are a couple of other options you and your wife could explore for arousal. The use of testosterone has been beneficial for 50 to 60 percent of the women in my practice who've tried it. Testosterone is by prescription and off-label for women, which means a discussion with her health care provider is required.

Other prescription options include localized estrogen, Osphena, or Intrarosa (a recently available FDA-approved choice). Any of these would increase blood supply by "estrogenizing" the genitals, which can improve arousal and orgasm as well.

Congratulations on undertaking this exploration together! Good communication and mutual support are so important to shared intimacy.

Lubricants: A Refresher

Okay. We’ve talked about sexual lubricants before. Many times. And for good reason. Vaginal dryness and the associated pain with sex, penetration, and sometimes daily life is possibly the #1 issue I deal with in my practice.

Insufficient lubrication during sex isn’t just a problem of menopause—many women experience it at various times of life—during pregnancy, with insufficient foreplay, or while on certain medications, for example. Or just because.

Fortunately, sexual lubricants are an easy, safe way to make sex more comfortable and fun.

Vaginal lubricants

One critical distinction: Lubricants are for use during sex to increase comfort and reduce friction. They coat whatever surface they’re applied to (including the penis and sex toys) but they aren’t absorbed by the skin, thus, they have to be (or naturally are) washed off. Moisturizers, on the other hand, are specially formulated to soften and moisten vaginal tissue. Like any lotion, they should be used regularly and are absorbed into vaginal and vulvar tissue. Moisturizers are for maintenance; lubricants are for sexual comfort.

Basically, there are three types of sexual lubricants: water-based, silicone, and a newer hybrid formulation. Each has unique characteristics and limitations. Water-based lubes are thick, feel natural, don’t stain, and don’t damage silicone toys. They rinse off easily with water. However, they tend to dry out more quickly (although they can be re-activated with water) and don’t provide long-lasting lubrication. Water-based lubricants may contain glycerin, which tastes sweet but can exacerbate yeast infections. 

Silicone lubes are the powerhouse of personal lubricants. They tend to feel slick and last three times as long as water-based options. They’re hypoallergenic, odorless, and tasteless. They may stain, and they will destroy silicone surfaces on other equipment, so you can’t use silicone lubes on your expensive silicone vibrator. They wash away with soap and water.

Hybrid lubes, as the name suggests, have some characteristics and benefits of both water-based and silicone.

At this life stage, you can put away your coupons and dispense with frugality. Your vagina deserves the best! Not only have those tissues become more delicate, your vagina also has a finely balanced pH level that (usually) protects against yeast and bacterial infections. Cheap or homemade lubricants can seriously mess with tender tissue and that natural acidity.

Some lubes contain “warming” ingredients, such as capsaicin, the ingredient that gives chili peppers their heat, or minty, or menthol-y oils. They’re intended to enhance sensation, increase blood flow to the genitals, and create a “tingly-warm” feeling. As such, they’re good for foreplay and use on vulva, clitoris, penis, nipples, external vaginal tissue, but not internally if they contain essential oil.

Use warming oils and lubricants with caution, however, since delicate or dry vulvar-vaginal tissue may respond with a fiery-hot rather than pleasantly warm sensation.

Use only products recommended for vaginal lubrication—not baby oil, vegetable or essential oils, petroleum jelly, or saliva. (Note: Oil destroys the latex in condoms and leaves behind a film that is a bacteria magnet.) Look for organic, natural, and high-quality ingredients (we look for these for our shop).

Each individual (and couple) ends up with one or more faves when it comes to lubricants. So make this a fun exploration for the products that work best, both for solo and couple play. If you don’t like one lube, a different type or brand might be just the ticket; don’t give up on lubes altogether.

Because the options for various lubricants are legion, we’ve tried to narrow the field in search of only the most effective and safest products for our shop. We examine the ingredients and opt for the most natural and organic brands possible. We also look at the philosophy of the company that makes them. We’ve been known to do quite a bit of research “in the field,” as well.

In the spirit of experimentation, we’ve put together a selection of seven sachets of water, hybrid, and silicone-based lubes in a handy sample kit. You can give them a whirl without the investment in a full bottle of lube that ends up in your sock drawer.

New lubricant options appear with some regularity, and we evaluate and add them periodically. If you’ve found something you love, let us know; other women may be happy to learn about the option!

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