Q: What help is available for difficulty penetrating?

Tightening of the vaginal opening is one of the effects women can experience from the loss of estrogen. The type of lubricants that offers the most "slipperiness" and the least resistance is silicone; Pink and Uberlube are  the most popular at MiddlesexMD in that category.

It is possible to gradually, gently, and comfortably stretch the vaginal opening by using vaginal dilators. These are available in a set of graduated sizes; start with the smallest (and plenty of lubricant) in daily exercises and, when comfortable, progress to the next-larger size.

Only rarely is surgical modification appropriate for addressing this condition. With patience, women can typically achieve comfort with dilators and lubricants.

Q: Would a vibrator be less irritating than manual stimulation?

If you're experiencing some irritation with clitoral stimulation, you might start with a hybrid (Sliquid Organics) or a silicone lubricant (Pink or Pjur). They provide more slipperiness for longer than their water-based counterparts.

And I would recommend that you try a vibrator. You can vary the intensity of the vibration, the pattern of vibration (continuous or pulsed, for example), and the pressure you (or your partner) apply--all helpful to finding what you need *now* for arousal. I'd recommend the Fin as an external options that is versatile, have nice soft surfaces, and can be recharged. The Kiri is a battery-operated, waterproof option with similar features.

Finally, if you're using a localized hormone like Premarin internally, with an applicator, there may be no added benefit from using a vaginal moisturizer. There's no harm in trying it, though, and I encourage moisturizer use among women who are not using localized hormones. If you choose to, Yes is the preferred product for many women who come to MiddlesexMD.

Q: Any cautions for oils to use for total body massage near the vagina?

You're right to be concerned, since the vulva and opening to the vagina can be easily irritated--and more so after menopause without estrogen therapy. Vitamin E oil can be used both for massage and lubrication. Liquid Silk is a lubricant that many women find soothing applied in the vaginal area. Most things that are flavored or heavily scented have the potential to be irritating to that delicate skin.

We've also liked Zestra, an arousal oil designed to use externally on the vulva. Its warming characteristics can be helpful in "reawakening" sensations as part of an intimate massage. As with any warming product, try just a small amount first to be sure it isn't irritating.

After Cancer: Take Care of Your Vagina

Whether you were already menopausal or were abruptly deposited into menopause after treatment for your cancer, you’re probably familiar with what happens to your vagina when you lose estrogen.

You may experience the burning, itching pain of thin, dry vaginal walls and fragile skin on your genitals. You don’t lubricate like you used to, so sex can be difficult or painful. Or, if you’re experiencing the muscle spasms of vaginismus, sex may be impossible. Less estrogen is a good thing for some cancer treatments, but it’s darned tough on the vagina and, by extension, on your sex life as well.

So, while vaginal health is important for all women during menopause, it’s critical for those undergoing cancer treatment. Your vagina and pelvic floor need a lot of TLC right now to stay comfortable and responsive. Fortunately, compared to the other things going on in your life, taking care of your bottom is usually straightforward and inexpensive. Besides, keeping your vagina in good shape might eliminate one problem area and allow you to stay in touch with your sexual self, too.

Consider this four-part approach to caring for your vagina and pelvic floor.

First, use vaginal moisturizers and lubricants.

Moisturizers are your first line of defense. These are non-hormonal, over-the-counter products that are intended to keep your vagina hydrated and to restore a more natural pH balance. They should be used two or three times a week, just as you’d moisturize any other part of your body. Lubrigyn, PrevaLeaf Oasis, and Emerita are examples of moisturizers.

Using moisturizers is important whether or not you’re having intercourse. It should just be part of a regular health maintenance regimen.

Use lubricants liberally before intercourse, on sex toys such as vibrators, and any time you touch the delicate tissue on your genitalia. Also apply lubricant to your partner’s penis.

At this point, keep your lubricants plain and simple—no scents or flavors; avoid warming lubes. Don’t use any product with glycerin, which can create an environment conducive to yeast infections, and don’t use petroleum-based lubricants.

Second, keep your pelvic floor toned. “The pelvic floor is really important in keeping your internal organs in place, preventing incontinence, and enhancing sexual pleasure,” says Maureen Ryan, nurse practitioner and sex therapist.

Plus, knowing how to relax your pelvic floor muscles is helpful if you’re experiencing the involuntarily spasms of vaginismus.

Kegel exercises, in which you flex and relax the muscles around your vagina, will tone the pelvic floor. Or, you can purchase exercise tools to tone your pelvic floor muscles. This is a great way to make sure you’re exercising the right muscles.

Third, use dilators if your vaginal capacity is compromised. Dilators are cylinders that come in sets with various sizes. They’re meant to gradually increase the size and capacity of the vaginal opening, which can be important, especially after some cancer surgeries and treatments that constrict the vaginal opening or create scars and adhesions.

To some extent, dilators are helpful just to reassure you that you can tolerate something in your vagina again.

Start with the smallest size dilator, lubricate it, and gently insert it as far in as you can tolerate. Try doing kegel exercises, tensing and relaxing your pelvic floor muscles. Can you feel your muscles close around the dilator? Keep it in for maybe ten minutes and repeat this exercise several times a week. Move on to the next largest size when you can tolerate it.

Fourth, use a vibrator (lubricated, of course). Self-stimulation increases blood flow to your genitals and helps reacquaint you with the feelings and sensations of your body. The more stimulation you can bring to the area, the healthier it will be.

The point is to keep the vulvo-vaginal area moist and flexible, to increase blood flow, to stay responsive, to maintain capacity, so that when you and your honey are ready to start your engines, you’ll both enjoy a smooth ride.

Patience, patience!

So you arrive home from a hectic day at the office, and there's the box you've been waiting for, with your new lube, a vaginal moisturizer, and those dilators that have promised to return your sex life from painful to normal. "Oh boy!" you think. "Orgasm tonight!"

Please, please, please, slow down. I know it's hard to wait when you've been anxious to find an answer.

The conditions that cause painful intercourse in the first place can be comforted and in many cases reversed, but only with practice and time. Practice and time that are worth taking, when the result is the kind of sexual intimacy you want.

Picture a young athlete. She is powerful, flexible, supple, and graceful. She practices her sport every morning and night. Then she graduates, gets a desk job, has a couple of kids, spends nearly every waking hour sitting at her desk or in her mini-van, carpooling. Her fitness slowly drains away.

One day, she decides to get back into shape. If she tries to complete a workout at the level she did when she was in peak condition, she will get hurt. No doubt about it. She knows, or will soon realize, that she must start slowly. She'll get her fitness back, but only if she works within her comfort zone. When things start to hurt, she needs to back off. Keep moving, but slow down, decrease the intensity. Please approach your new sexual aids, your vibrator of course, your vaginal dilators, especially, with this same understanding. Pushing too hard, going too fast, will hurt you. You are trying to restore pleasure, and I recommend letting comfort and pleasure be your guide.

As always, if the pain just won't resolve, do discuss it with your doctors. Finding the real reason for the pain is the fastest way to resolve it.

Meantime, put the box down. Have a healthy dinner. Take a nice bath. Relax. Then begin, slowly.