Q: What's the G-spot got to do with orgasm?

Great question! Unfortunately, there's enough controversy about the answer to have warranted a whole blog post on the subject. The short answer, though, is that the G-spot (named for the German gynecologist Ernst Grafenberg, who talked about it in the 1950s) is a sexually sensitive area about a third of the way up the anterior (front) vaginal wall. There seems to be a rich plexus of nerves just beneath the vaginal surface in that area, which, when stimulated, may produce a variety of feelings: discomfort, urge to urinate, or pleasure. Some believe–and experience–that stimulation in that area leads to orgasm; this may be the specific source of vaginal orgasm (as opposed to the more-common orgasm from clitoral stimulation).

Being aware of the discussion of and theories of the G-spot is great; so is experimenting to see what sensations are present for you, in a spirit of creativity. Don't assume there's a "should" or an "ought" that you're missing. Please explore your own body, and embrace your own personal sexuality!

To ask your own question, use the pink “Ask Dr. Barb” button top and center on our website. You’ll receive a confidential reply via email, and your question may be used as the basis for a Q&A post here on our blog. 

Q: What stopped my orgasms?

You mention a variety of things that play a role, all coinciding with the change in hormone levels that comes with menopause, which you'll reach in a few more months (the milestone is one year without menstruation).

The Vagifem that's been prescribed for you should be having some positive effect with vaginal dryness; it should not interfere with orgasm. Vagifem is a very, very low dose of estrogen, delivered directly to the vagina and surrounding tissues. This is partial compensation for the estrogen delivered through the whole body when ovaries are intact and functioning.

SSRIs (selective serotonin reuptake inhibitors, a type of antidepressant), which you mention taking, can be a barrier to orgasm. If you've taken them for a while and only recently have had issues, it could be that the combination of the SSRIs and the lower hormone levels of menopause is now problematic. There is limited evidence that Viagra can help women on SSRIs experience orgasm. It's not just estrogen that declines with menopause: Testosterone also declines. You might talk to your health care provider about testosterone therapy; among my patients, many who trial testosterone note sexual benefits, usually describing more sexual thoughts, more receptivity (a patient recently told me she's "more easily coerced"!), and more accessible orgasms.

You also said that vibrator use has become ineffective for orgasm. Among midlife women, I find that the specific vibrator really counts. There is a definite range of vibration intensity, and as our bodies change, that can make all the difference. Lelo has just doubled the "motor strength" of two of their already powerful (and MiddlesexMD favorites) vibrators for the Gigi2 and Liv2.

Best of luck! My work with women every day says it's worth exploring your options. (And, to take the pressure off, remember that intimacy without orgasm is still intimacy!)

To ask your own question, use the pink “Ask Dr. Barb” button top and center on our website. You’ll receive a confidential reply via email, and your question may be used as the basis for a Q&A post here on our blog. 

Ringing the Love Button

Maybe you gathered from last week's post that the clitoris is command central of the female orgasm. Perched atop the labia minora, its sole purpose and function is sexual pleasure. It has more nerve endings than the penis, and—although affected by conditions that reduce blood supply—it can retain sensitivity as you age.

Most of the clitoris is out of sight, extending deep within and around your vagina and labia. “The most recent anatomical research suggests that the clitoris is perhaps better described as the 'clitoral complex,' where the vagina, urethra, and clitoris all function as a unit rather than as individual parts," says Dr. Debby Herbenick, in this article for Men’s Health.

Unlike the penis, the clitoris can orgasm repeatedly without a refactory (rest) period. Clitoral orgasms also last from between 10 to 30 seconds and involve from 3 to 15 contractions, which can reach from the abdomen to the vagina.

So, rather than creating artificial divisions and hierarchies between whether an orgasm is vaginal or clitoral, why not view the whole area as one big erogenous zone? Clitoral orgasms involve the vagina and vice versa, so neither is “better” or more desirable. Every orgasm is right on the money. Use what works, rather than focusing on the vagina, which as you know, can get a little cranky right about now.

And if you can coach your partner on some clitoral finesse, lovemaking could take on a whole new dimension.

Let’s return to the fact that the clitoris, as we mentioned before, is “homologous” to a penis—it has the same biological features. Thus, it has to be treated gently. Too much or too rough and it’ll either hurt or go numb. So start slow and gentle.

To begin, use lube on your fingers. (Your partner’s tongue is great.) Start a vibrator on low. The glans (head) is usually too sensitive to touch directly, so stroke the hood over the top of the glans, stroke around the labia minora and the vaginal vestibule. Stroke inner thighs, breasts, nipples. Use round and round and over the top motion on the clitoris.

For the partner: Tongue action on and around the clitoris is very erotic. Done well, it can make her “come” all by itself. Don’t jump into action. Get things warmed up with your best foreplay action.

Then, with lubed fingers begin a gentle, playful massage downtown—gently stroke her inner labia, across, over and around her clitoris. As your partner becomes aroused, slide between her legs and begin using your tongue, licking firmly up the tiny shaft of the clitoris, using separate strokes at first. Vary the action with quick darting motions on the exposed glans or by flicking her clitoris with your tongue. Begin using a firmer, continual stroke without breaking contact until she begins to orgasm.

You can then quickly move to penis-in-vagina action until you orgasm, or you can cup her “mound” with the palm of your hand, applying gentle pressure to her clitoris, which feels very comforting.

You don’t have to go crazy with the tongue action (how exhausting that would be!). Set the scene well with foreplay; keep the action gentle and varied, increasing both the frequency and firmness as she becomes aroused. Some handwork on her breast and nipples helps. And remember, practice makes perfect!

Good positions to increase clitoral contact during sex include the faithful missionary but with the partner pressing down to engage the clit. Either partner can reach the clitoris if she’s on top or in the rear entry position. “There's no need to be overly fancy during sex—the very best positions are the ones that focus on the clitoris,” says author and sexologist Dr. Logan Levkoff.

Finally, the clitoris needs good blood flow to be its best orgasmic self—and orgasms boost the immune system, support a healthy sleep cycle, and help keep your hormones balanced. You can keep clitoral blood flow through:

  • Exercise. “Twenty minutes of moderate exercise increases a woman's genital engorgement by 168 percent—and the effect persists for hours,” writes Weed. Go for a walk with your partner, she suggests.
  • Sex and masturbation. It’s the whole “use it or lose it” dichotomy. You have to keep the tissues plumped and primed or they atrophy, especially as you age.
  • Clitoral pump. That’s the whole purpose of this handy device—bringing blood and, ergo, sensation and function, to the clitoris. In no way should a pump replace the first two parts.
Clitoral stimulation techniques of your own? Please share.

Fifteen Facts about Your Vagina

Out of sight; out of mind. That’s how it is with the vagina. As long as it’s working and isn’t causing a fuss (which, granted, becomes more iffy at this stage of the game), we forget about it.

Nothing wrong with that.

But, ladies, your vagina is a marvelous thing, so in the interest of a little community ed on this underappreciated organ, here are some fun and quirky facts—maybe things you didn't know—about your vagina.

  1. The word vagina comes from the Latin word for “sheath” or “scabbard.” Those Latin lovers were all about their swords. The word orgasm originated with the Sanskrit word for “strength.”
  2. The hymen is named after, um, Hymen, the Greek goddess of marriage. It’s a membrane that partially covers the vaginal opening before puberty to protect it until normal changes during puberty. It’s broken with a girl’s first sexual penetration, and the attendant show of blood is the traditional “proof” of her virginity.
  3. As you might imagine, the vagina has accumulated many colorful names over the centuries. A few of the, ahem, more decorous are: camel toe, honeypot, cock pocket, vajayjay, meat wallet, muff, bearded clam, fish taco, crotch mackerel, hot pocket, bikini biscuit, panty hamster, yum yum, twat, hoo ha, and, of course, pussy and cunt. Enough already!
  4. The vagina proper begins at the mouth of the vulva and ends at the cervix, which is that bottlestopper at the base of the uterus. So the vagina is the conduit—the “potential space,” the empty sock without a foot in it—that leads from outside the body to the small opening in the cervix that allows sperm to pass through.
  5. While the vagina is only 3-4 inches long, it balloons to 200 percent its normal size (to accommodate those Latin swords as well as babies of various sizes). This impressive ballooning effect happens because the vagina is pleated like a skirt with a bunch of folds, called rugae, which expand when extra space is needed.
  6. We talked about the normal variations in the way your outer genitalia may look, but for the most part, vaginas all look the same.
  7. Like your oven, your vagina is self-cleaning. So, for heaven’s sake, don’t douche. You’ll upset the delicate balance of good bacteria that live in there. Wash your external genitals with warm water and some gentle, unscented soap.
  8. Your vagina has its own unique odor, which is determined by your diet, the normal variation in bacteria, sweat, and hygiene.
  9. Your pubic hair isn’t just an annoying decoration. In days of yore, it was a “reproductive billboard” announcing that over yonder was a fertile female. It also traps your scent, leading suitors to the honey pot. Times have changed since caveman days, and a healthy mat of hair may not be quite so irresistible today. Pubic hair has a life expectancy of only three weeks versus head hair, which stays put for about seven years.
  10. The normal pH balance in your vagina is slightly acidic, similar to wine or tomatoes. That normal balance can get out of whack if you have an infection, douche, or through exposure to semen, which is more alkaline.
  11. Sex keeps your vagina moist and flexible, especially after estrogen levels drop. “Safe vaginal intercourse can help keep the vagina healthy and dilated,” says Dr. Courtney Leigh Barnes, a gynecologist at the University of Missouri in this article.
  12. Vaginal farts (also called queefs or varts) happen to every female at one time or another, especially during sex or exercise. So don’t be embarrassed.
  13. Gravity is as hard on your vagina as it is on your breasts, face, and buttocks. It sags, and sometimes, it falls out. This is called a prolapse. While it may be uncomfortable, it’s usually painless and can be fixed.
  14. Most women (about 70 percent) don’t orgasm through vaginal stimulation alone, but through a combination of clitoral and G-spot action.
  15. The first two inches in the vagina have the most nerve endings and are the most sensitive.
Don't say we never told you.

Priming the Pump for Better Orgasms

I never knew what it meant to prime a pump until I watched a plumber work on one at my cottage. To prime a pump means to pour a little water into its fill cap to create suction and, with luck, to pressurize the thing so it draws water rather than spurting air.

The hydraulics metaphor may be more appropriate for men, but I’m betting that some of your orgasmic pressure has leaked out over the years, too. Or, maybe it wasn’t very dependable to begin with. According to some studies, from 25 to 50 percent of women have trouble achieving orgasm.

There are, however, ways to repressurize your orgasmic system—techniques that may help get the sexual juices flowing again. It’s not magic—there is still no pink Viagra that guarantees an orgasm, given that the female sexual response cycle is a lot more complicated than a water pump.

If your orgasmic mechanism needs a little priming, here some holistic ways to repressurize.

  1. Exercise. (I heard that groan.) Good orgasms require good circulation to keep all that oxygenated blood flowing to your genitals. Aging does a number on the blood flow and nerve endings in the genital area, making them sluggish and less responsive.  Exercise helps maintain good circulation. It also keeps blood circulating nicely to the brain, which, as we’ve said, is really your biggest sex organ.
  2. Kegels. C’mon. These are easy and painless (there are tools available), and they do you a lot of good. Kegels tone and strengthen your pelvic floor muscles; those muscles keep you from leaking urine when you sneeze as well as holding your internal organs in place. Strong pelvic floor muscles also create a firm “vaginal embrace,” which is nice for your man, but also gives you a more powerful orgasm.
  3. Check your medications. Several categories of drugs are libido killers, including some antidepressants, but also some drugs that reduce cholesterol and high blood pressure. If you suspect that your meds may be messing with your sex drive, talk to your doctor.
  4. Masturbate. You need good circulation down there, right? Self-pleasuring helps. It also helps you identify what you like and how to “do it” the way you like it—so you can tell your partner.
  5. Get a vibrator and other sex toys. There are all sorts of physical reasons to use a vibrator. (See #4 above.) Toys may help you release some inhibitions and learn to play.
  6. Drink a little (not a lot.) Sharing a little pre-sex cocktail can create a cozy sense of intimacy and also help lower your inhibitions. Drinking too much is a libido-killer. Share a glass of wine in front of the fireplace and move the action to the bedroom—or keep it by the fireplace.
  7. Fantasize. Think of it as your personal romance novel. You can sleep with anyone you want and do anything you want. You’re only limited by your imagination. Fantasy helps some women “get into their heads.” Try it.
  8. Positions. If you’ve been using your vibrator, you know where your sweet spots are, and the missionary position often misses them. Try the back entry “doggie-style” position which is good for hitting the G-spot, although not so good for the clitoris, or try sitting on his lap, which is good for all kinds of things.
  9. Foreplay. If you take seriously Esther Perel’s statement that, for erotic couples, “foreplay pretty much starts at the end of the previous orgasm,” you may extrapolate that good sex arises from consciously introducing sensuality into your relationship in a sustained way. Touch. Snuggle. Sextext. Write love notes. Introduce beauty and sensuality into your life that might leach into lovemaking as well.
  10. Have sex. This cannot be repeated too often. The more you have it, the more you want it, and the better at it you become. As one happily married husband said: “Practice, practice, practice.”

Q: Why did I orgasm while breastfeeding?

Remember oxytocin? It's a hormone that facilitated the let-down of milk when you were nursing, and it's released with nipple stimulation. Oxytocin also stimulates contractions for the uterus (which is why any of you who had labor induced might recognize oxytocin by another name: pitocin). Outside of childbearing, oxytocin works with other sex hormones to facilitate orgasm and increase the intensity of pelvic floor muscles. Oxytocin levels have also been noted to fluctuate  throughout menstrual cycles, correlating with lubrication.

This is a hormone that has lots of favorable effects on sex! There has been research in using it to enhance sexual function, but there's not a product readily available yet. Stay tuned!

Q: Why do I have cramps after a hysterectomy?

You describe cramps, not unlike menstrual cramps, after masturbation. Orgasm includes contraction of pelvic floor muscles, and it sounds like you're experiencing some spasms of those muscles. Radical hysterectomies often require tissue removal or dissection surrounding the uterus and ovaries. It's likely your spasms are caused within nerves and muscles that are still healing.

I suspect this will improve with continued healing, but using an anti-inflammatory medication like ibuprofen may help relieve the pain. If, three months or so after surgery, when most healing has taken place, the spasms and pain persist, a consultation with a pelvic floor physical therapist may be helpful. They can assess the muscles and nerves of the pelvic floor and often remedy persistent pain.

Continue that healing work! I'm hopeful the pain will resolve itself.

Q: How will hypothyroidism affect me sexually?

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.

An Hysterical History

As we saw in the last post, vibrators were developed by doctors in the late 1800s to replace the “pelvic finger massage” they routinely administered to female patients. The massage was intended to relieve symptoms of “hysteria” or “neurasthenia,” such as anxiety, sleeplessness, and general malaise. Done successfully, it induced a “hysterical paroxysm,” which offered temporary relief to patients. By some estimates, over 75 percent of women suffered from these symptoms.

By the early 1900s, small electric vibrators had a comfy niche in middle-class homes right on the shelf between the toaster and the electric iron. At the time, they were perceived as medical devices that had nothing to do with sex.

The porn industry, however, was not so easily deluded. In the late 1920s, early porn films embraced the gadget for its own version of “doctor.” In this context, the “hysterical paroxysm” looked unmistakably like (gasp!) an orgasm. Once that connection was made, the veneer of the vibrator as a nonsexual treatment for a medical condition became uncomfortably hard to sustain, and the vibrator quietly disappeared from respectable society and doctors’ offices.

It became so utterly invisible, in fact, that in the 1970s only 1 percent of women had ever used one, according to the Hite Report, a famous study of female sexuality. “This was perhaps unsurprising, given that most vibrators by then were modeled on a very male notion of what a woman would want–a supersized phallus–replicating, in other words, the very anatomy whose shortcomings had precipitated the invention in the first place,” writes Decca Aitkenhead, in the Guardian.

At the heart of the matter was that:

  • At the time, women (of a certain social class) were simultaneously idealized and condescended to. They weren’t supposed to be sexual, to want sex, or to enjoy it.
  • The only “real” sex was penis-in-vagina penetration until the male reached orgasm.
  • If this didn’t satisfy a woman, the fault was hers. She was either defective, frigid, or “out of sorts” (in Victorian parlance).

Rachel Maines, author of The Technology of the Orgasm, the seminal work tracing the history of the vibrator, commented in an article in the Daily Beast, “In effect, doctors inherited the job of producing orgasm in women because it was a job nobody else wanted. The vibrator inherited the job when they got tired of it, too.”

That many women were not completely (or at all) satisfied by ordinary coitus was a source of confusion, frustration, and threat to some men. According to the Hite Report, most women can reach clitoral orgasm through masturbation. But the idea of women masturbating was also extremely threatening.

“I have read debates between doctors over whether women should be allowed to ride bicycles or whether the pleasure they might induce from the seat made it an unacceptable moral hazard,” writes Erik Loomis in “The Strange, Fascinating History of the Vibrator.”

Lest you think that we’ve evolved beyond these repressive and delusional ideas and that female sexuality is more acceptable today, think of the recent diatribe against a college student who spoke in favor of requiring health insurers to provide contraception. Or the statements alluding to “legitimate rape,” or the suggestion that a woman can’t get pregnant because her body “will shut the whole thing down.”

Have we really come all that far, Baby?

In any case, the discredited vibrator slunk back into view in the 1960s, first as a kinky sex toy and then as a symbol of women’s sexual liberation by feminists.

In a major national study of sexual behavior conducted in 2009, of over 2,000 women surveyed, 52.5 said they had used a vibrator.

If nothing else, the peculiar story of the vibrator should help us recognize how strongly we are influenced by cultural messages. A vibrator is not a medical device nor is it some unsavory symbol of sexual deficiency. For those of us who need extra stimulation to keep our sexual parts lubricated and functional, it’s just one important tool.

Hysteria, the Movie, or: What Doctors Did for Victorian Women

Just released on September 21, Hysteria is a light comedy about a dark and silly time. So touchy is its topic, in fact, that it took the producer, who is a woman, about ten years to find a studio willing to back the project. So unnerving is the topic that the author of the book on which the movie is based, who is also a woman, lost her job as an assistant professor when it was published.

Hysteria, the movie, and the book, titled The Technology of Orgasm by Rachel Maines, explore the modern history of the vibrator. And a surprising story it is. The movie, which stars Maggie Gyllenhaal and Hugh Dancy, approaches the topic with a comedic touch. It is described by Movieline.com as “spirited, a jaunty trifle that’s low on eroticism but high on cartoony coquettishness.”

But beneath the silliness—because, really, how else can this be portrayed?—lies the basically true story of the invention of the vibrator. The unnerving truth may be that the paternalistic and harebrained notions that led to the invention of the vibrator continue to entangle themselves in our “modern” cultural psyche. The movie, but more insistently the book, raises some instructive and faintly unsavory questions about embedded cultural expectations regarding women and sex.

First, we’ll look at the vibrator story, and then, in a future post, we’ll explore the cultural attitudes lurking beneath.

If you’ve ever read novels from the late 1800s—the Victorian period in England—such as those by Jane Austen or the Brontë sisters or Edith Wharton in New York, you may have noticed a certain… reticence… a naiveté, an innocence about sexual matters. “Making love” in these novels refers to the most innocuous verbal expressions of admiration. Respectable women were corseted, cosseted, and shielded from turbulence of any sort. The preoccupation of a young woman was to attract a suitable match, and having done so, she was to run an efficient household and be an asset to her husband. Little was heard of her henceforth.

Having read many of these novels, I’ve often wondered how children were ever conceived.

So I was amazed to discover that these same respectable Victorian women were prescribed a very unusual medical procedure by their doctors to alleviate emotional afflictions, which were diagnosed generally as “hysteria” or “neurasthenia.” Symptoms ranged from anxiety and nervousness to headache and sleeping difficulty to abdominal “heaviness.”

A procedure that seemed to temporarily relieve these symptoms was known as a “pelvic finger massage,” typically administered by those very proper doctors. The goal of this treatment was to induce a “hysterical paroxysm.”

So—to put it in contemporary terms—doctors were masturbating their female patients to orgasm in order to relieve the sexual (and other) frustrations that women in this era commonly experienced. And this in a culture that viewed a glimpse of ankle as risqué.

“It's very difficult to imagine that 100 years ago women didn't have the vote, yet they were going to a doctor's office to get masturbated,” said Gyllenhaal in an interview with the UK’s Guardian.

At the time, however, the procedure wasn’t thought to be sexual. In fact, doctors considered it routine, tedious, and boring.

“Annoyed doctors complained that it took women forever to achieve this relief,” writes Eric Loomis in “The Strange, Fascinating History of the Vibrator.” Yet, since repeat business was virtually assured, doctors weren’t complaining about the steady income.

So, they invented a machine to do it for them. Thus the vibrator was born.

Early models ranged from comic to frightening. A steam-powered vibrator called the Manipulator, invented by an American doctor in 1869, required the patient to lie on a table with a cutout at the business end. A moving rod was powered by the steam engine in another room.

Lack of mobility was a problem with this contraption—a doctor was committed to a large, stationary object that consumed two rooms. And if the engine was coal-powered, who did the shoveling?

The next model was electric, and the battery only weighed 40 pounds. This was developed by Dr. J. Mortimer Granville, our erstwhile hero in the movie Hysteria. So it was that the vibrator predated the invention of the vacuum cleaner or the electric iron by over a decade. I ask you, where are our priorities, ladies?

Despite their size and lack of attention to attractive design, the things worked. From over an hour of manual manipulation, a woman could now reach “paroxysm” in five minutes.

But progress marches on, and by the turn of the last century, more domestic households had electricity, and vibrators had become small, portable, and widely available. Reputable magazines and catalogs sold them alongside the toaster and the eggbeater. A woman could buy a “massager” for what a few visits to the doctor cost, and thus the medical profession lost its cash cow.

Advertisements in magazines like Women’s Home Companion, Sears & Roebuck, and Good Housekeeping promised that “all the pleasures of youth… will throb within you” and “it can be applied more rapidly, uniformly and deeply than by hand and for as long a period as may be desired.”

It beggars the imagination to believe that no one through all these decades considered that massaging a woman’s genitals had anything to do with sex. And in fact, the Guardian article states, “Despite the lack of evidence to suggest otherwise, it seems unlikely [that women really did not know what they were buying]–and the manufacturers surely knew what they were selling.”

This level of schizophrenia is the vexing conundrum at the heart of the vibrator phenomenon.

In a future post, we’ll explore the more recent history of the vibrator and the questions suggested by this massive blind spot.