When Size Matters

A recent report in The Journal of Sexual Medicine caught my eye. “Vibrators and Other Sex Toys Are Commonly Recommended to Patients, but Does Size Matter? Dimensions of Commonly Sold Products” is the title. First, I was happy to see that the authors are furthering the discussion about health care providers telling patients about “vibrators and other sex toys” (and, full disclosure, my article in OBG Management is footnoted as among the voices encouraging physicians to consider what they offer women through their practices).

Beyond that encouragement, the researchers compiled dimensions of vibrators and dildos, noting that not every source provides accurate or complete information. The conclusions they reached were that while the size of products varied, the dimensions, overall, “approximated mean penile dimensions.” They further suggested that further familiarity with the product category among clinicians, which is never a bad idea.

Since I’ve been recommending vibrators to women (and men) for some time, I’ve got some practical observations to share, for both patients and clinicians.

First, don’t do anything that hurts. Really.

The corollary to that is that you get to decide what hurts and what feels good. There are no “shoulds.” That’s true even if someone has a chart of dimensions and predictions.

I find that women like vibrators that can be inserted into the vagina for three reasons:

  • They like the feeling of fullness (and for them a dildo is also effective)
  • They like direct stimulation of the G-spot (which, as we’ve said before, has a mystique all its own)
  • While they don’t specifically think of the G-spot, they like the internal stimulation

Their favorite toys are as varied as the women themselves, and dimensions are only one part of that equation. Materials, pulse patterns, and vibration strength also count. Sexual partners and history can have an influence, as can progression of menopause, which can mean narrowing and shortening of the vagina. Over time, women may want a shorter, narrower vibrator, quite possibly with a stronger motor for more intense sensations.

But, again: Using a vibrator should feel good. If a vibrator is too large to comfortably insert, don’t insert it—or wait until you’re more fully aroused before you try again. And regardless of “insertable length,” don’t feel like there’s anyone but you who decides how deep to go.

And if insertion doesn’t sound good or feel good, remember there are a number of vibrators designed to stimulate the clitoris, which is where the nerve endings are concentrated that 70 percent of us need for orgasm.

So if your health care provider is still studying up, don’t be discouraged. Women have more than 100 years of experience using their own judgment with vibrators and pleasure, and you can do the same.

April 15, 2015

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orgasm ›   Q&A ›   sexual intimacy ›   SSRI ›  


Q: Which of my medications is inhibiting my orgasm?

You say you’re taking daily doses of Wellbutrin and Effexor. Effexor is the likely culprit, since Wellbutrin is actually “pro-sexual.”  Wellbutrin increases dopamine, a neurotransmitter beneficial for sex; Effexor increases serotonin, a neurotransmitter that is negative for sex—in that it can decrease libido or ability to experience orgasm.

If you can decrease the dose of Effexor without an increase in other symptoms, that may help. Decreasing the dosage may mean other symptoms comes back, or that orgasm is still out of reach or diminished. In those cases, I offer Viagra, used off-label for women. A number of clinical trials have shown Viagra to be helpful when SSRIs (selective serotonin reuptake inhibitors, a class of treatments for depression and other disorders) lead to an inability to experience orgasm.

A newer SSRI, Pristiq, is reported to have fewer negative sexual side effects. I’ve seen that to be true, but also have worked with patients who found that health insurance was not supportive, since newer drugs are often more expensive. It may be worth exploring!

Another alternative that works for some women is to take a ‘drug holiday': skip the daily dosage of the SSRI on a weekend day when they are more likely to be sexual. This doesn’t work for everyone. Some people have withdrawal symptoms or other unintended side effects with the ‘holiday approach.’

I encourage women in my practice to consider using a vibrator, which can increase sensation and sometimes lead to orgasm. At midlife, it’s important to stay sexually active (that ‘use it or lose it’ thing), so it’s worth the effort to experiment.

I see how frustrating this dilemma is for women to manage through! I wish you patience and perseverance to find the right balance of overall health and intimacy for you.

Q: Which of my medications is inhibiting my orgasm?

You say you're taking daily doses of Wellbutrin and Effexor. Effexor is the likely culprit, since Wellbutrin is actually "pro-sexual."  Wellbutrin increases dopamine, a neurotransmitter beneficial for sex; Effexor increases serotonin, a neurotransmitter that is negative for sex—in that it can decrease libido or ability to experience orgasm.

If you can decrease the dose of Effexor without an increase in other symptoms, that may help. Decreasing the dosage may mean other symptoms comes back, or that orgasm is still out of reach or diminished. In those cases, I offer Viagra, used off-label for women. A number of clinical trials have shown Viagra to be helpful when SSRIs (selective serotonin reuptake inhibitors, a class of treatments for depression and other disorders) lead to an inability to experience orgasm.

A newer SSRI, Pristiq, is reported to have fewer negative sexual side effects. I've seen that to be true, but also have worked with patients who found that health insurance was not supportive, since newer drugs are often more expensive. It may be worth exploring!

Another alternative that works for some women is to take a 'drug holiday': skip the daily dosage of the SSRI on a weekend day when they are more likely to be sexual. This doesn't work for everyone. Some people have withdrawal symptoms or other unintended side effects with the 'holiday approach.'

I encourage women in my practice to consider using a vibrator, which can increase sensation and sometimes lead to orgasm. At midlife, it's important to stay sexually active (that 'use it or lose it' thing), so it's worth the effort to experiment.

I see how frustrating this dilemma is for women to manage through! I wish you patience and perseverance to find the right balance of overall health and intimacy for you.

Vibrator Myth-Busting

Recently, I joined with two colleagues to produce a “continuing medical education” unit for the American College of Obstetricians and Gynecologists (ACOG). Our topic was “Vibrators and Other Devices in Gynecologic Practices” (if you’re a health care practitioner, you can investigate the CME offer here).

I was joined by Mary Jo Rapini, a sex psychotherapist and long-time friend of MiddlesexMD, and Debra Wickman, a gynecologist who teaches at the Banner Good Samaritan Medical Center in Phoenix. We talked about a 2009 study in the Journal of Sexual Medicine that says that 52.5 percent of women have used a vibrator; that led us to talk about the roughly half who have not.

A number of myths might get in their way, and we hope we made some progress in busting them.

Myth #1: Vibrators are for people whose relationships are in trouble. Based on what the three of us have seen, the opposite is true. As Mary Jo explains, “Vibrators are for couples who want to explore, who want to try new things, who want to play and have fun in their sex life.” Couples who share that desire are typically interested, trusting, and care about each other.

Myth #2: Vibrators make it hard to have an orgasm any other way. I’m happy to debunk this one with a medical reality: As the muscles involved in orgasm grow stronger, orgasm becomes easier and more intense. Vibrators are good at stimulating—and they don’t get tired or fumble, as we sometimes do as we lose a little strength and dexterity. Staying sexually active with a vibrator will increase your responsiveness to manual stimulation—that’s just the way we work.

Myth #3: There’s something sinful about a vibrator. Again, it’s Mary Jo who addresses this most directly. She’s had a number of conversations with faith leaders on her patients’ behalf, when religious concerns weighed on their minds. The ministers she’s talked to are invariably in favor of keeping marriages strong, and maintaining physical intimacy is a natural part of those relationships.

Myth #4: Vibrators are only for self-stimulation. Vibrators are good for self-stimulation, and that’s a good option for women who want to maintain their sexual health when they’re without a partner. But they’re also part of intimacy for couples. They’re especially good for couples who see a need to slow down and spend more time in foreplay. Which, now that I think about it, could be any of us who’ve achieved midlife!

If you’re among those who haven’t tried a vibrator, I support your right to decide for yourself. Here’s hoping, though, that none of these myths is what’s standing in your way.

"Eating at the Y": Why It's a Good Thing

I may be going out on a limb here, but I’d like to make a case for oral sex. It gives us another avenue to intimacy and pleasure, and as such, is an important component of a lusty love life. It’s a skill that couples should try to develop. Or at least keep an open mind toward.

Here’s why.

First, most women (70 percent. Did you get that number?) don’t climax with vaginal penetration alone. In my practice, postmenopausal women commonly tell me that the only way they can orgasm is through clitoral stimulation or oral sex.

For all women, no matter the age, the most dependable orgasm is clitoral—which, as we’ve said before, is a powerful organ with twice as many nerve endings as the penis.

Sure, the clitoris (and the penis) can be stimulated in many creative ways, but the mouth and tongue are darned effective.

Second, I know I sound like a broken record, but we lose sensitivity and the ability to lubricate vaginally as we age. And our partner’s ability to maintain an erection will eventually wane as well, despite the little blue pill. As the old penis-in-vagina sex becomes less dependable, it’s helpful to have other tricks up our sleeve.

Oral sex is one way to keep sexual pleasure alive as a couple. No less venerable an institution than the AARP says so in this article. It makes sense to give ourselves alternatives and room for compensation, so that when one capability diminishes, another can fill in the gap.

Now, I’m not for a minute suggesting that you haven’t tried oral sex. Sex coach Kathleen Baldwin, says that “It’s somewhat rare in my experience to find a woman over 40 who doesn’t enjoy oral sex.” She thinks that mature women are less influenced by cultural norms and are more familiar with how their bodies function, including their lady parts.

For many women, however, the “yuck” factor presents an impediment. Some women consider their genitalia “gross.” They worry about cleanliness or odor. They worry that it will take them too long to climax.

Funny thing is, most men really like oral sex—both giving and receiving it. I ran across an article by a man on the topic, who writes:

It’s an amazing feeling to satisfy a woman, and cunnilingus is the most foolproof way to do it. It also minimizes our own performance phobia. Women can’t see what we’re doing, our tongues will never need Viagra and we’ve all got a similarly sized piece of equipment. But most of all, [cunnilingus] is a five-sense experience that places us up close and personal in a way that no other act can. …most vaginas smell and taste pleasantly mild…

The pleasure you can give your partner (and ultimately yourself) may be worth getting over any squeamishness. And you can always address the cleanliness issue by showering (or a bath!) before sex.

Oral sex, whether cunnilingus (oral sex to a woman’s genitalia) or fellatio (oral sex to a man’s genitalia) works best with some technique, and like any other skill, practice makes perfect. The most direct path to improvement is communication. You have to let your partner know what feels good. (More on technique in the next post.)

One final consideration: if you aren’t sure about your partner’s status with regard to sexually transmitted disease (STDs): you can still transmit them with oral sex. Chances of infection are lower, but Chlamydia, gonorrhea, herpes, human papyllomavirus (HPV), even HIV can still be “caught” through oral sex. For example, one woman I know caught genital herpes from a cold sore on her husband’s mouth!

So, if you’re with a new partner and you aren’t completely knowledgeable about his or her sexual history, you need to use protection—a dental dam (piece of latex placed over the vulva) condom, or femidom (female condom).

Kind of takes away the sexy, but it sure beats the alternative.

Oral sex is just another way of expressing intimacy and sharing pleasure. And it’s a particularly nice option if more traditional forms of lovemaking become problematic. Well, heck. It’s a nice option any time.

Q: Why am I "skipping" orgasm?

What you describe is going from arousal to "resolution," without experiencing what you used to as orgasm in between.

The first thing I'd check if you came to my office is whether you're on any medications that could interfere with orgasm. The biggest class of medications in this category are the SSRIs—antidepressants like Prozac and Zoloft. If you are, you can talk to your health care provider about alternatives that would have the effects you need without the same side effects.

Difficulty with arousal and orgasm are more common as our hormones change through menopause. The loss of estrogen diminishes blood supply to the genitals, which affects sexual response. There are a few ways to counter that loss:

  • More direct clitoral (external) stimulation can help—and not all of us are accustomed to needing that. A good vibrator is effective; we encourage women to consider vibrators with stronger-than-average vibration strength, and choose the products we offer at MiddlesexMD with that in mind.
  • Localized vaginal estrogen can also be helpful; you'll need to talk to your health care provider to see whether a prescription is appropriate for you.
  • Keeping the pelvic floor muscles in shape is a critical piece of enjoyable sex, too. Strong muscles are part of strong orgasms--as well as preventing incontinence. We offer a new product, the Intensity pelvic tone vibrator, that uses electrical stimulation to contract the pelvic floor muscles in addition to its vibration patterns.

One more thing to consider: Women have at 50 about half the testosterone she had at 25, and testosterone plays a critical role in libido and ability to orgasm. There's no FDA-approved product for women, unfortunately, but I prescribe testosterone off-label for patients with good results. Off-label use of Viagra or Cialis is also helpful to a few women. All of these off-label prescriptions require a conversation with your health care provider—and consideration of your overall health.

There's every reason to be optimistic about regaining satisfying orgasm!

Reading between the Lines

I have a lot of conversations with women about sex, given my line of work. And, because of that little pink “Ask Dr. Barb” button on our website, I get some cryptic emails, too. Sometimes I have to read between the lines, both in person and online, to understand what the situation—and therefore the question—might be.

One recent email referred to male partners who were not especially “gifted.” As I think about it, I suspect that my correspondent was wondering about her own orgasm—or her failure to experience it. That’s not the topic we corresponded about, since she went on to ask a different question, but because I’m sure that woman is not alone, let me lay it out here.

In spite of the passionate scenes we see in movies, most of us—70 percent—don’t experience orgasm during intercourse without additional stimulation. For most of us, it’s the clitoris that’s the key to orgasm, and most positions for intercourse just don’t provide enough stimulation. There are other sources of stimulation that can lead to orgasm—some of us have very sensitive nipples, for example, and some of us have found success with the G-spot.

It’s rare for a partner, whether “gifted” or not, to be psychic; and most women I know would prefer that their partner not be too widely experienced in the varieties of women’s responses. And that’s why I encourage women to know their own bodies, exploring either on their own or in the presence of their partners (many of whom find the experience quite erotic, by the way). Vibrators have proven to be very effective in clitoral stimulation; adding internal stimulation is helpful for about a third of us.

When you find what works for you, you can give your partner some suggestions, which will be much appreciated. (If, by the way, you’re wondering whether you’ve experienced an orgasm, keep exploring. You’ll know when you have.)

Ninety-six percent of us can experience orgasm. Be assured of that and relax. Being focused on that goal can inhibit your ability to achieve it. And let’s affirm one more time that sex can be pleasurable without orgasm, too, for the intimacy you share with your partner, for the feeling of wholeness and power it gives you.

Another email exchange—with a woman who experienced her first orgasm at 70—confirms that it’s never too late.

Q: Why would I need physical therapy for the pelvis?

The pelvic floor is made up of multiple muscles and supporting tendons. They act like a hammock or trampoline to support a number of vital organs: the bladder and urethra, uterus and vagina, and rectum and anus, to name a few. It's a very unique area of the body, involving organs that play a role in varied and important functions: urination, defecation, sex, and childbirth.

Many things can disrupt the proper function of the pelvic floor; childbirth, natural aging, and menopause are common. Surgery can have an immediate effect. Sexual trauma may result in damage, and so can actions as simple as lifting or coughing. Symptoms of the pelvic floor not behaving properly might be urinary incontinence (involuntary loss of urine), painful sex, or constipation or difficulty moving bowels. Pelvic organ prolapse can cause or exacerbate some of those symptoms; that's when one or more of the organs resting on the pelvic floor sag into one another.

A discussion with your provider about your symptoms, accompanied by a good pelvic exam, can help in determining whether pelvic physical therapy is likely to help your condition. To get the best outcome it is best to find someone who specializes in this area of the body. A great pelvic physical therapist can work magic!

A common reason for referring to physical therapy is urinary incontinence. As part of treatment, physical therapists use electrical muscle stimulation, employing devices that stimulate the muscles of the pelvic floor to teach them to properly contract and relax. Several of these devices recently became available for home use. In addition to increasing continence, Intensity also treats orgasmic dysfunction (difficulty achieving orgasm). It works in two ways: providing electrical stimulation to the pelvic muscles (you increase the stimulation as the muscles get stronger) and offering a very intense vibration that improves the ability to orgasm. Orgasm is, after all, a series of very intense muscle contractions; as the muscles grow stronger, you improve orgasm. So far my patients have given Intensity two thumbs up! Other, lower-tech options to improve pelvic floor muscle function are vaginal weights and barbells.

Q: Will I ever orgasm?

You may be among the 4 percent who won't experience orgasm--who, for some reason, simply can't, under any circumstances. It's more likely that you're among the 96 percent who can. When a woman tells me she's not sure if she's experienced orgasm, I say she probably hasn't; it's fairly obvious when it happens.

Most women need direct clitoral stimulation to reach orgasm; what we see so often in movies, of partners climaxing together through intercourse alone, is rare in real life. Beyond that, there's plenty of variation: Some women may need an hour of clitoral stimulation; others may experience orgasm through brief nipple stimulation.

I recommend that each woman know her own clitoris, because degrees and types of pleasurable stimulation vary among us. Vibrators are very effective in stimulating the clitoris, and spending time yourself, exploring in a relaxed environment, will help you advise your partner on what feels good. Soothing or arousing music or a sexy scene from a movie can help, too.

When you're ready to go further, you can try internal stimulation, which leads to orgasm for about 30 percent of us. A vibrator like the Gigi2 can be used both externally and internally, so you can place it in the vagina (use a lubricant to be sure you're comfortable) and see what happens.

While chances are good (about 96 percent good!), there's no guarantee of orgasm. And because being focused only on orgasm can actually inhibit your ability to experience it, I hope you'll enjoy the intimacy and other sensations along the way!

Q: Could I be too stressed to orgasm?

You say that you're both excited and anxious about being with your partner, but that you're tense with him and haven't experienced this before. Let me first say that there's no magic pill that will solve this problem.

For women, sharing sexual intimacy requires the ultimate in trusting, giving, and sharing. This emotional component is just one part of a complex whole for women, but it's the place I'd start. I'm curious about whether you're tense with this partner in situations outside the bedroom, and whether you've been able to express your concern. It would be helpful it it's a problem you're looking to solve together rather than a "performance anxiety" issue for you alone. Being anxious about being able to experience orgasm only makes it more difficult!

You might consider seeing a therapist with a focus in sexuality to be sure that you're clear on the emotions and feelings you're experiencing.

If there is no emotional barrier to address, I've recommended Viagra or a very low dose of testosterone for women who have lost orgasm or intensity; both of these drugs are rescribed "off label," which means they're FDA-approved for another use.

I wonder whether you're able to experience orgasm with self-stimulation; if you haven't tried, I encourage you to. A vibrator used either alone or with your partner may provide the increased sensation you need. And if you're able to orgasm alone, you may learn some things about your response that you could share with your partner.

Sex is often complicated, with multiple interdependent components; it doesn't help that our bodies change as we gain years! Please do look to a therapist for any emotional considerations; if physical considerations remain, a health care provider knowledgeable about menopause can help you evaluate options. Most women in my practice are able to reclaim this part of their pleasure!