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


painful sex ›   physical therapy ›  

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! 

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! 


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.

November 17, 2016


menopause ›   painful sex ›  

Q: Sex is painful, but it’s not dryness. Help?

You asked. Dr. Barb answered.To know the ultimate solution for treatment of painful intercourse, it’s important to know the exact cause of the pain. If it is vulvovaginal atrophy, then a vaginal estrogen, like Estrace vaginal cream (which you say you’re using), or Osphena, a non-hormonal oral medication, should be helpful. But not every option works for 100 percent of women, so if this is the diagnosis and you are not responding, another product should be considered.

There may also be another diagnosis apparent after a thorough exam. The condition you describe may be vulvodynia, which is referred to by a variety of names including provoked vulvodynia, localized vulvodynia, or vestibulodynia. I normally hear a description of burning, tearing, sandpaper-like, usually near the opening of the vagina.

Another cause of pain can be vaginismus, which results from too much tone of the pelvic floor muscles and results in painful intercourse. It’s the involuntary spasm of the muscles, which prevents or limits penetration.

Please persevere to get both a diagnosis you trust and a treatment that’s effective for you!

November 14, 2016


intimacy ›   menopause ›   painful sex ›  

Q: What will make intercourse less painful?

You say you’re past menopause, which is defined as a year without menstruating. Intercourse has become painful, and occasionally you have some bleeding afterwards.

The condition that leads to painful intercourse in menopause is vulvovaginal atrophy, now called genitourinary syndrome of menopause. The absence of estrogen leads to profound changes to the genitals. The vagina and vulva shrink, and the tissues are more dry, thin, and fragile. This leads to painful sex. Within five years of menopause, up to half of women have pain with intercourse.

Early in menopause, before the atrophy is advanced, vaginal moisturizers can be beneficial; they are considered part of prevention. But once the atrophy is more advanced, moisturizers are not enough.

You asked. Dr. Barb answered.You can restore health by adding a localized (vaginal) estrogen or using Osphena (an oral, non-estrogen treatment). Both of those options are prescription therapies that reverse the atrophy and restore health to the vagina, vulva, and lower urinary tract. A good lubricant is definitely important too, I recommend Pink, a silicone lubricant with aloe and vitamin E.

Occasionally, there can be an additional cause--beyond atrophy--for painful intercourse. A careful examination by a menopause care provider will help determine the exact cause and whether any additional treatment would be helpful.

Best of luck! With patience and persistence, most women can regain comfortable and satisfying intimacy!



Q: Will sex be painful the rest of my life?

You say you’ve had painful intercourse for a few years, and were hoping it would pass. You tend not to want to have sex because the perception of pain outweighs the perception of pleasure. No surprise! And you’re not at all alone, for whatever comfort that gives you.

Once a woman transitions through menopause, she will be postmenopausal for the rest of her life. That means there is no source of estrogen, which results in what we call chronic and progressive vaginal atrophy. The effects of this are increasing vaginal dryness and thinning and narrowing of the vagina. This is not something that will reverse itself over time; without treatment, it only progresses. (I know! This is not something our mothers prepared us to expect!)

You asked. Dr. Barb answered.The majority of postmenopausal women who want to continue to have intercourse need to compensate for the loss of estrogen. The Premarin vaginal cream you refer to using is one option for treatment; it’s a long-term treatment, not a “cure.” It replaces the estrogen your body used to produce, directly in the area where it can have positive effect. This localized hormone treatment is preferred for women whose only issue is painful intercourse. There are fewer risks associated with it than with systemic hormone therapy (called HT or HRT, for hormone replacement therapy), which introduces hormones to more systems in your body.

If your painful intercourse isn’t adequately treated with the Premarin cream, there may be a secondary cause of pain, like vaginismus or vulvodynia. It is important to give feedback to your health care provider to be sure that the sources of pain are properly identified and treated.

It may be that your tissues are now healthy, but because you’ve avoided intercourse you could now benefit from vaginal dilators. Regular use of dilators will gradually stretch your vaginal tissues so that intercourse is comfortable again.

Alas, the sexual enjoyment that came so easily, with so little effort, is now a different story. But I hope you find the efforts of regaining sexual comfort worth the time and energy! I’m privileged to hear from patients about their successes, so I know it can happen!

September 28, 2016


painful sex ›   women's sexual health ›  

Q: Why is sex painful after childbirth?

You asked. Dr. Barb answered.There are a variety of reasons that sex can be painful after birth. It may be pelvic floor muscles that are still too taut, injured, or spasmed. There may be some nerve damage that is still healing. In those cases, allow time for recovery--and do be in touch with your health care provider if you have questions or don’t think you’re progressing.

If the mother is breastfeeding, there’s can be a reduction in estrogen that contributes to vaginal dryness. In those cases, a silicone lubricant (Pink Silicone is our most popular in this category) can be very helpful.

In any case, I encourage new mothers to be forthcoming in their follow-up medical visits: Returning to a comfortable sex life is, ideally, a part of the new family “normal”! Whether or not your health care provider asks about your sexual health, please bring up your questions or concerns.

Q: Is there an alternative to HRT to combat vaginal atrophy?

You say you have not been sexually active for several years, and that recently a Pap test was painful to endure. Your doctor diagnosed vaginal atrophy. For reasons of your own health history and your family’s, you’re reluctant to use HRT (systemic hormone replacement, now called HT for hormone therapy).

Vaginal atrophy is a condition we characterize as chronic and progressive. It will not improve on its own and will get more uncomfortable over time. Initiating treatment sooner than later is usually advisable. Many treatments (like vaginal moisturizers) that maintain vaginal health are not effective at restoring vaginal tissues.

If you want to try a vaginal moisturizer as a first step, I’d recommend Lubrigyn Cream as a good option. It contains hyaluronic acid and elastin to maintain and support the tissue structure. We have other options in our shop if you’d like to experiment.

You had to ask. Dr. Barb answered.Localized estrogen--applied vaginally--is among the most effective ways to restore the integrity of an atrophic vulva/vagina. I do understand your hesitation about systemic hormones, but localized hormones don’t carry the same risk factors (it’s an option for breast cancer survivors, for example). And if your only menopause symptom is vulva/vagina-related then a localized treatment option is usually a great choice.

Osphena, a non-estrogen oral, daily treatment, is another prescription option that has been effective for my patients in restoring vaginal comfort. Here’s a blog post I published when it was first approved, and I’ve been using it successfully in my practice since.

You also asked about the MonaLisa Touch treatment, which uses laser treatment to stimulate the vagina to make collagen and develop a new layer of vaginal tissue. I don’t have direct personal experience with it, but have investigated it for my practice and find the research compelling. Pain and side effects are minimal, and the treatment appears to provide relief to 85 to 90 percent of women who have it. Definitely worth discussing with your health care provider!

Your age seems to be young to consider never experiencing a normal sex life again! (I admit that my threshold for expectation rises with my own age, but more treatment options are available each year.) With some effort, I’m quite certain you can revive that part of your life.

Q: What moisturizer would you recommend if ingredient sensitivities?

I think the Prevaleaf products are likely a good option for you. The Oasis Natural Daily Vaginal Moisturizer is paraben- and fragrance-free, as well as pH-balanced for the vaginal environment. Regular use is key to healthy tissues, which typically means less irritation.

Because you mention burning sensations after application, you might also like Soothe Natural Vaginal Soothing Cream. Like the moisturizer, it’s made with natural ingredients; it’s formulated for rapid absorption.

You asked. Dr. Barb answered.Your complaint of burning suggests the possibility of vulvodynia, a condition that results in burning pain with intercourse; anything that comes in contact with the area (near the opening of the vagina) can be experienced as burning or irritating. A careful pelvic exam can help  determine if you have “simple” vaginal (or “urogenital”) atrophy or vulvodynia. If the former, the Prevaleaf products should be helpful and well-tolerated; other options might be explored if it’s the latter.