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.
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, the sexual lubricants are an easy, safe way to make sex more comfortable and fun.
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.
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.
Silicone lubes are the powerhouse of personal lubricants. They tend to feel slick and last three times as long as the water-based option. 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 anywhere near your expensive silicone vibrator. They wash away with soap and water.
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.
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!
When it comes to sex, friction is bad; lubrication is good. Nicely lubricated surfaces not only protect delicate vaginal tissue, but revitalize the sexual experience.
That’s why we talk a lot about personal lubricants here at MiddlesexMD. Sexual lubricant is part of a regimen of vaginal health that is meant to keep vaginal tissues moist and sex pleasurable. This goes for all ages, not just menopausal women.
So, in the interest of great sex (we’re always looking out for you, sister!), here are six tips to help you choose and use your lube:
1. Use one! This is general good advice for young and old(er). It will revitalize your sex life and help to keep it pain-free.
2. Experiment. What do you like? Thick or slick? Warm or cool? Tasty or—not? Lube choice is as personal as eye color. And there is no shortage to choose from. Sexual lubricants are sold online and over-the-counter in every conceivable permutation of flavor, color, and promise of ecstasy. As we said in this post, it’s hard to even determine a trend among our clients.
Here are the main categories:
Water-based lubes are thick and easy to wash off, but they don’t last as long as silicone-based or hybrid lubes. They are safe for use with silicone vibrators and sex toys.
Silicone-based lubricants are slippery and long-lasting. They don’t dissolve in water, so they’re good for sex play in the hot tub or shower. They do coat the vagina, however, so you may need a good, soapy clean-up. Silicone lubes may also stain clothes and bed linens. And you can’t use a silicone lube with a silicone-surfaced toy or vibrator. This includes the E-string vaginal ring, which delivers hormones to the vagina and is partly made of silicone.
Hybrid lubricants are the newest kid on the lubrication scene. They’re mostly water with a bit of silicone, so the texture is both thick and slick. Hybrids last longer than water-based lubes, tend not to stain, and wash off more easily. You can use them with silicone toys.
A good place to start? Our Personal Lubricant Selection Kit. We’ll send you sachets of 7 different lubricants: water-based, silicone, and hybrid, along with a card to choose your favorite. Return the card, and you get a full-size bottle of that lubricant. So much better than having a collection of leftovers of lubes you don’t like!
3. Vet your lube. Your hardworking vagina deserves nothing but the best. Not only that, vaginal tissue is very absorbent, so those substances end up directly in your bloodstream.
Check the ingredients in any lube you’re about to buy. Avoid products with parabens and any compound ending with –paraben (this is a preservative that acts like estrogen in your system) and polypropylene glycol (a thickener with some unpleasant side-effects). If you’re among the women prone to yeast infections, you may want to avoid glycerin. Check out fragrances; when they’re safe and natural, they can enhance your experience, but they’re not necessary, so not worth a chemical risk.
Bottom line: Your lube should be as natural as possible. In our shop, these water-based lubricants are good options, especially for people with allergies or skin irritations: Good Clean Love Almost Naked or Restore, Sliquid Organics Natural Gel, Yes, and Aloe Cadabra.
4. Keep it healthy. Vaginal tissue becomes more delicate as we age. Plus, it has a specific Ph balance to inhibit yeast and other infections. You can disrupt that balance or introduce harmful bacteria by using saliva, oil, petroleum jelly, body massage oils, or anything not specifically formulated for the vagina.
5. Keep it handy. What good is a lube if it’s stored in the bathroom down the hall? Keep your lube (better yet—a couple varieties, depending on the vibe that night) beside the bed. Carry sachets in your purse because—you never know.
6. Make it sexy. Lubes are all about fun and comfort, so don’t be stingy. Use it on his penis for some slick hand work or in the condom or on the condom, if you use them. (And you do use them under these circumstances, right?) Put some on your nipples or lube your breasts and slide them over his body. Aren’t the options enticing? You’ve got your lube, now get creative.
You ask whether there's an over-the-counter hormonal cream to restore vaginal elasticity. You're finding intercourse painful and experiencing dryness.
Vaginal moisturizers will help to retain some moisture, but none of them will reverse the process—which is, medically speaking, atrophy given the loss of estrogen. The combination of moisturizers and lubricants will keep things comfortable for a while, but most women eventually need more.
Localized estrogen or the new pharmaceutical Osphena are effective; either requires a consultation with your health care provider. I'm not aware of any hormone-based medication available over the counter and, in fact, encourage a consideration of your medical history and current factors before use.
While the cream you describe would be fine with the dilators themselves, we doctors recommend against using oils in the vagina. Oils tend to promote the growth of bacteria and break down or weaken tissues. Lubricants especially made for vaginal use are worth the investment.
The dryness, discomfort, and frequent infections you describe are consistent with vulvovaginal atrophy (now sometimes called "genitourinary syndrome of menopause") and, possibly, vulvodynia. The mainstay of treatment for these conditions is to "estrogenize"--add estrogen to--the vagina.
It was once thought that all estrogen posed some vascular risk, so I understand the hesitation about continued use for you after a blood clot. More recently, though, localized (placed directly in the vagina rather than taken orally) estrogen has been shown not to raise the risk of thrombosis. Estrogen products still carry the "black box warning," regardless of the method of administration. About a month ago, though, additional data were presented to the FDA asking them to remove that "class labeling," since the means of administering makes such a difference. We'll see what happens, but you can ask your health care provider to reconsider.
In addition to continuing the use of a vaginal moisturizer, you might also use a silicone lubricant (Pink is a favorite at MiddlesexMD). That type of lubricant reduces friction and gives more glide or slipperiness. And you could ask your health care provider to prescribe a topical xylocaine, an anesthetic that you can apply to the area to make you more comfortable during and after intercourse.
Have another discussion with your health care provider, and try all your options! Comfortable sex is possible for you.
The best option for what you describe is a regular routine of vaginal moisturizer use; use it consistently at least two times a week. Add a lubricant at the time of intercourse to assure your comfort.
Estring, a vaginal ring, is one method for delivering localized hormones—in this case estradiol. The ring itself includes silicone polymers, so I recommend to my patients that they use a water-based or hybrid lubricant. Among water-based lubricants, Yes and Aloe Cadabra are often ordered. Sliquid Organics Silk is popular among post-menopausal women; as a hybrid lubricant, it has the benefits of water-based but is more long lasting, like silicone-based.
Silicone-based lubricants aren't recommended for use with products made from
silicone—like the Estring and some vibrators or other sex toys—because the formula may cause disintegration of the surface.
Hypothyroidism, which is a low-functioning thyroid gland, is quite common in women; about one in eight will have thyroid disease in her lifetime. Interestingly, there's been little research in understanding how thyroid function may affect sexual function.
The good news is that treatment for hypothyroidism—supplementation of thyroid hormone—is straightforward, and women receiving treatment seem to have little or no increase in sexual issues. Those who are not treated seem to have more issues with desire, lubrication, and orgasm.
As women get older, their risk of having thyroid disease increases. There are both physical symptoms (like weight gain, dry and yellowish skin, hair loss, fatigue, muscle or joint aches and pains) and cognitive symptoms (like slower thinking or speech, memory issues), but at age 50 and thereafter I recommend a screening—simple blood tests—at regular intervals.
According to a recent New York Times article, women now have available a plethora of products meant to boost “feminine arousal.” And they’re appearing not behind the pharmacist’s counter, but in over-the-counter products in major pharmacies, right beside the Vaporub and Ace wraps.
Many of these products contain blends of botanicals and oils and “secret-recipe” ingredients designed to boost a woman’s sexual response. I wish some of them would carry more information for the user so that, for example, some oils aren’t unintentionally used internally when they’re best only for external massage. As with many beauty products, some strike me as setting unrealistic expectations (or even sending unfortunate messages), as with “anti-aging creams” for the vagina, clitoris, and inner thighs.
Few of these products have been objectively tested for efficacy or safety, so it’s a “buyer beware”—or, I’d rather say, “buyer be informed” marketplace. Zestra’s oil is the only arousal product that has been subjected to a randomized clinical trial in which it “significantly” outperformed a placebo. Too many products are promoted with only survey results, which are not the same thing as a clinical trial.
As the Times article noted (and we’ve stated many times), the trouble with female libido is that it’s complicated. Everything from mood to culture and personal beliefs to hormonal imbalances can affect a woman’s ability to “get it on.”
And in fact, a woman’s lack of libido also affects her partner’s sexual pleasure. Dr. Michael Krychman, gynecologist and MiddlesexMD advisor, notes that men often neglect to fill their Viagra prescriptions because their partner’s sexual issues remain unaddressed.
Finding a one-size-fits-all silver sex bullet is like looking for fairy dust. Most of us have to develop a multi-pronged regimen to keep our sex drive functional, especially as we get older. We could abide by the Hippocratic principle to “do no harm,” and given that these products are, by-and-large, indeed harmless, and that they may do some good, why not give them a trial of your own? Use a site like ours to inform yourself about what might be worth looking for or avoiding (we have this advice, for example, about choosing a lubricant), and then make some room for some playfulness.
“Do they work for serious issues? No. But do they work to make your sex life more fun? Maybe. There’s certainly no harm in trying,” says Dr. Bat Sheva Marcus in the Times article.