Q: What do you recommend for pain that interferes with intimacy?

Your description of pain with the vaginal opening makes me think a really careful exam is your next step. It sounds like vulvodynia (also called vestibulodynia) should be considered. This condition results in pain with penetration, usually described as a burning or tearing sensation.

A lubricant can make penetration less uncomfortable, but it doesn't make it comfortable.

Another possibility is that the absence of estrogen has led to atrophy, resulting in the loss of caliber (size of the opening) of the vagina. If that's the case, using vaginal dilators may restore size and comfort.

In either case, I'd encourage you to see your healthcare practitioner. Stick with it! I know you can be comfortable and revive your sex life!

Sex Therapy: Not So Scary after All!

A few months ago we talked about couples therapy, which caused some discussion about a closely related field: sex therapy. The idea of going to a sex therapist may be so scary that you wouldn’t even consider it! You’re probably not alone. That’s why we decided to talk with Sarah Young, MA, who is a sexual therapy specialist whose practice is Christian-based.

Sarah was educated at the Institute for Sexual Wholeness in Atlanta; her philosophy is that sex is not just sacred, it’s meant to be enjoyed. “It’s still such a taboo issue,” she says. Her goal is to help people find a “voice” for their sex lives, to talk about it and explore it freely without shame or guilt. She had so many interesting things to say, we’ve divided the information up into two parts; here, she talks about getting started:

Q: What’s the biggest “fear factor” or misconception women have about sex therapy?

A: Sex is such a personal, intimate thing. They’re afraid they’re going to have to get naked and perform: Oh, my gosh, am I going to have to take my clothes off and show her what we do? That’s not how it works at all.

Q: Let’s talk about how it does work: How do you get started?

A: A lot of my referrals come from doctors working with women, so I’ll usually start with the woman. We’ll just have a conversation at first. Patients often ask how I got into sex therapy, and that gives me the opportunity to establish my professionalism, my ethics, and how I feel about the sacredness of sex, which always makes them feel more comfortable.

Then we’ll begin by talking about the bigger picture, her world as a whole: What are her other life stressors? I need to get an idea of everything that’s going on in her life, the larger dynamic, because it’s all entwined in the bigger circle. It’s not, Okay, give me all the details and let’s go.

Facing failure goes against what Hollywood says your sex life should be; it’s very threatening for people. So I try to validate her in that first session ­— here’s where you are and this is fine — and to offer her hope.

Then in the second session, I’ll usually engage in a pretty in-depth sexual history just to find out where she’s coming from. What are her automatic thoughts, how has her body image been formed, and what other experiences are in her reality? Some of the questions are very difficult for people, like whether she is masturbating, and if so, how often.

Once we uncover all the issues, we’ll talk about a game plan. At that point, I usually give it three weeks to a month between sessions, so they can just go through a cycle of life. Because you need to give this time; one week you might have a hormone issue, the next week, everything is okay. You need that whole cycle to give it a framework.

Q: What kinds of issues do you typically deal with in older women?

A: One big thing, of course, is menopause and all the changes that come with it. Women sometimes feel defective when they’re going through it, which is understandable. Often it’s a matter of shifting their perspective to just normalizing it; it is what it is, you need to take it one chunk at a time.

Other issues might be aging in general, or a partner’s infidelity, or the reality of cancer and mastectomies: How am I still supposed to feel sexy when my breasts are gone? And the empty nesters: The kids have gone off and mom and dad haven’t paid attention to each other for years. Now all of a sudden, she’s thinking, I don’t even know how to be his friend, let alone his lover. So a lot of it is empowering people to reignite the passion and the friendship they once had; they’re in a place when they can engage in a more mature perspective.

Q: Once a person starts therapy, how long might it last?

A: It really depends… I have couples I’ll see every few weeks for three months and they’ll check in after that every few months to update, or if they’ve hit a glitch or want to talk through it. Every case is different, really.

Watch for part two of Sarah’s interview, in which we discuss partners’ roles and therapy techniques used; you can see it next week!

Q: Will dilators help with vaginal atrophy?

Dilators don't treat vaginal atrophy, but they do help counter a consequence of vaginal atrophy: narrowing or shortening of the vaginal. Used over time in graduated sizes, dilators help to restore vaginal length and width, which we also call vaginal capacity.

The loss of estrogen leads to vaginal atrophy. Using vaginal moisturizers and/or vaginal estrogen helps to restore tissue health. In turn, healthy tissue responds well to the use of vaginal dilators for comfortable intercourse!

It helps to understand the varied effects of a reduction in hormones. You can read the whole story on our website in what we call "the recipe" for continued sexual health!

Sex: It’s Good For What Ails You

Who has time for sex any more? That’s a question I hear from women whose plates are full with working, caring for parents, caring for kids, even caring for grandchildren. With all of the demands on our time and energy, why not just let sex fade into the background? Beyond the intimacy sex brings to our relationships, research continues to document how and why regular sex improves both our mental and physical health. These effects are significant enough to feel as good about an active sex life as about taking our daily vitamins. Consider, for example, that sex is
  • a beauty treatment. Intercourse releases estrogen, which helps keep skin firm and hair shiny.
  • a good aerobic workout. A moderately strenuous 30-minute frolic burns about 85 calories. (A vigorous, one-hour session can burn up to 200 calories!) Not only that, it gets your heart pumping. Pulse rates rise from about 70 beats per minute to an athletic 150. Finally, intercouse tones the butt, belly, and those all-important pelvic-floor muscles that are so critical to bladder control.
  • a natural chill pill. Sex lowers blood pressure and relieves stress. One study revealed that simply being hugged by their partners lowered women’s blood pressure and raised their oxytocin levels.
  • an antibiotic. Regular sex is linked to higher levels of the infection-fighting antibody immunoglobulin A (IgA).
  • a love potion. Sex pumps up to five times the normal levels of oxytocin into our systems just before orgasm. This chemical has been called the “love drug.” It makes people feel trusting, bonded, intimate, and generous—all good things for a relationship.
  • a pain killer. Those high levels of oxytocin release endorphins into the bloodstream, which can lower pain thresholds by half. Intercourse has been known to relieve aches and pains, such as arthritis and headache.
  • an antidepressant. Again, the chemical and hormonal stew that sex unleashes, including oxytocin, endorphins, and serotonin, make us feel good in body and mind. The release of serotonin can stabilize anxiety and improve mood. It enhances our overall sense of well-being.
  • a cardiac protective factor. Regular sex (up to three times per week) could lower the risk of heart attack by half, according to a study at Queen’s University in Belfast.
With all these positive outcomes, sex is certainly “good for what ails you”--and can prevent ailments as well!

Three Cheers for Second Loves

If you read this blog regularly, you know that I usually summarize questions I receive from visitors to the website when I think the answers will be helpful to more people.

An e-mail I received today, though, makes me want to say more. The message was from a 63-year-old widower who says, I “have met the second love of my life, something I thought would never ever happen again.” He goes on to explain that he’s doing research because he and his new love have enjoyed intimacy, arousal, and orgasm, but have been unable to have intercourse.

Unfortunately, time and aging are not friends of the vagina. Without ongoing maintenance—meaning regular use and moisturizers—it is typical that a woman will lose function over time. The vagina narrows and shortens and the tissues become more fragile, as this couple have experienced.

Vaginal dilators are part of the solution for many women who’ve reached this point; most women can regain vaginal function in a matter of weeks. Using a moisturizer or vaginal estrogen at the same time helps to improve tissue health and elasticity.

What I found really encouraging about this e-mail was that it came from a man, a man who took the initiative to get information to equip himself and his partner to address these issues together. “I don’t want to hurt her,” he said; “I want to make love to her.”

Making love. It’s a reminder that our physical intimacy is something we create together with a partner, and that a partner has an interest in—and can help us—to overcome or work around physical changes that get in our way. As women, we don’t have to keep secrets or try to compensate for problems on our own.

And if we find ourselves without partners? Loving ourselves is part of remaining open—figuratively and literally—to those relationships that still surprise and delight us. It’s easier to maintain vaginal health and functionality than it is to regain it, and you’ll bypass the physical and emotional pain that this e-mailer described. Even if you think you’re done with relationships and sexual intimacy… well, the patients I see in my practice and the e-mails I receive at MiddlesexMD.com tell me to never say never—even when you’re sure it will “never ever happen again.”

I see it happen all the time. Has it happened to you?

When I Say I’m Hot…

Hot flashes. They’re the stereotypical symptom of menopause, the subject of T-shirts and mugs: “It’s not a hot flash, it’s a power surge.” But when you say to yourself or your partner, in an intimate moment, “I’m hot,” you want to feel sexy, not soaked.

Unfortunately, among the things that trigger hot flashes is arousal itself. And as uncomfortable as you may be—both physically and emotionally—this is no time to put your sexuality on hold. Remember our “use it or lose it” discussion?

There’s not a lot we can do to disconnect the arousal trigger for hot flashes. What we can do, though, is look at other triggers to make sure we’re not making ourselves overly susceptible.

  • Quit smoking. As a physician, I list that first because it contributes not only to hot flashes but also to other serious medical problems. I don’t smoke, so I know it’s easy for me to say, but if you’re still smoking at mid-life, it’s time to take that tough road to being smoke-free.
  • Drink less. A glass of wine can be part of a romantic evening, but be aware that alcohol can be a trigger for hot flashes. You can do your own experimentation to see if alcohol's a trigger for you, at what level and with which kind of alcohol.
  • Eat well. Smaller meals of low-fat, high-fiber food will keep your digestive system from heating up from overwork and acting as a trigger. Spicy food can also sometimes be an aggravating factor.
  • Exercise. Women who exercise regularly have fewer hot flashes than women who don’t. More good news: Sex is exercise!
  • De-stress. Easier said than done, I know, but the more stressed you are, the more hot flashes you’re likely to have. You can’t remove all the stressors from your life—some of them are people you love!—but you can develop mindfulness practices that help you manage them more easily.

On that romantic evening, especially, plan your activities to minimize your triggers. Drink cold beverages. Eat a light meal, not excessively spicy. Wear natural fabrics (like cotton) that will breathe and keep you cool. Make sure that the temperature in your bedroom is cool, or position a fan. Use cotton bedding and layers of light blankets that let you adjust. And remind yourself to keep breathing.

It might help reduce your anxiety (remember stress is a trigger!) to have a conversation with your partner about how to stay in the mood with a hot flash.

For a few of us, none of these strategies contains the damage, and hot flashes really interfere with our lives and sexuality. None of these options is perfect for everyone, but hormones, anti-depressants, and blood pressure medications have each had some positive effect. Your care provider can help you balance treatment of hot flashes with your health history and other medical conditions you may have.

And finally, remember that there is sex after hot flashes. Most of us, a year or two after menopause, are completely hot-flash-free. Staying sexually active through this transition keeps us able to continue to enjoy intimacy. Because, you know, we’re still hot!

Q: Could I have injured myself during sex?

You say you don't have issues with vaginal dryness, but you did feel discomfort--difficult to sit comfortably, spasms of pain--for at least a week after intercourse. It does sound as though you experienced some trauma.

It's likely that though you're still experiencing your own lubrication when stimulated, you're experiencing some atrophy, too. I'd suggest that you start using a vaginal moisturizer (like Yes or Replens) or a localized estrogen to maintain moisture all of the time--not just when you're aroused.

If you and your partner aren't able to be intimate often (and I'm afraid the definition of "often" varies from woman to woman), you might think about some of the additional options I talked about in a blog post about "Staying Ready for Sex." It's easier to maintain your sexuality than to restore it!

Sex and Depression

When a patient tells me that she no longer enjoys sex, one of first things I ask her is to tell me about something that she does enjoy.

If she isn’t able to come up with a fairly quick answer, in my experience it’s likely that depression is playing a part in her loss of libido.

Anhedonia -- the inability to gain pleasure from normally pleasurable experiences -- is a core clinical feature of depression. And because depression affects nearly twice as many women as men, and because recent studies suggest that midlife is a period of increased risk for depression in women, I am always on the alert when a patient mentions that she has stopped enjoying activities -- like sex -- that used to give her pleasure.

The cause-and-effect relationships between menopause and depression and between depression and loss of libido are complicated -- to say the least!

Some studies suggest that changes in hormonal levels, such as those that occur during the transition to menopause, may trigger depression. The production of mood-enhancing neurotransmitters is boosted by estrogen. Lower levels of estrogen that accompany menopause can mess with the brain’s chemical balance, leading to depression. Other biochemical changes that come with age, such as those that result from decreased thyroid function, have also been linked to the onset of depression.

But the pressures and stresses associated with midlife surely play a role as well. The loss of our youthful looks, of our reproductive and mothering roles, and sometimes even of our jobs or life partners -- all make us vulnerable to depression as we move into and through our menopausal years.

Whatever the cause -- and at whatever age -- depression has a significant impact on sexual function and enjoyment. Nearly half of all women -- and men -- diagnosed with depression report that it interferes with their sexuality.

The good news: If depression is behind your loss of interest in and enjoyment of sex, there is an array of proven treatments to relieve the underlying cause and its symptoms. Your doctor can help identify and treat medical causes, such as thyroid problems. In some cases, hormone replacement therapy that elevates estrogen levels may be effective. Antidepressants that help correct chemical imbalances in the brain help many (although these may have their own sexual side-effects). Regular exercise, improved sleep habits, and dietary changes can help to counteract depression, and counseling and support groups are other options to explore.

Don’t let depression drain the pleasure from your life. Talk to your doctor. See our website for more information on hormonal changes and therapeutic resources. And if you have experienced and overcome anhedonia in your own sex life, we’d love to hear your story!

The Ultimate Couples Project: Pain-Free Sex

I’m still thinking about the research that says lots of post-menopause women have sex even though it hurts. The study I read said many of them think there’s nothing that can be done—that painful sex is a normal part of being a mid-life woman.

I pick up clues to another obstacle in the e-mails I receive as Dr. Barb: We women are reluctant to include our partners in addressing difficulties with intercourse. I’m not sure why this is. Maybe we’re in denial about the changes we’re experiencing. Maybe we’re too used to being the caretakers in our households. Maybe we’re still shy about talking about our genitals and our pleasure.

If I overdo in the garden, my husband will give me a back rub. If a shipment of products for MiddlesexMD arrives after hours, he’ll help me carry the heavier boxes in. When we entertain, we clear the clutter together.

I guess I’m suggesting that you see maintaining your sexuality as the ultimate couples project. A partner who loves you will not want you to endure pain to give him pleasure; and will want you to enjoy intimacy as much as you are able.

You’ll have to talk about it—as you’d tell him where the muscles are knotted after weeding. You can send him this blog post or sit down with our website together to get the conversation moving.

He can plan to take more time to increase your arousal and natural lubrication. Together, you can use lubricant as part of foreplay to increase your comfort. The two of you can experiment with warming lubricants or a vibrator to increase your sensation. And your partner can support your work with dilators or other tools to regain your sexual health.

It’s not too much to ask. Really.

Great Expectations

A woman born in 1850 could expect to live just past her 40th birthday. A woman born in 1900 was likely to make it to 50—assuming she survived the flu epidemic of 1918 and other hazards. I looked up this life-expectancy data to help me understand why we have so little shared understanding of how menopause affects women.

We think of biology as something that changes very slowly, if at all. Since the beginning of time, we think, girls have menstruated, grown up into women, entered perimenopause, and then, at some point, achieved menopause. And then…

This is where the big change (no pun intended!) has happened. Our life expectancies have increased dramatically. Only 100 years ago, it was typical for women to die before they reached menopause. Our generation, in contrast, will live a third of our average-75-year lives post-menopause. Our granddaughters (born in 2000 or later) could be post-menopausal for closer to half of their 80-year-plus lives.

A third of our lives post-menopause? That’s good reason to make sure we women know that menopause is not the end of our sex lives. Sex is good for our health: it bolsters our immune systems, releases good hormones, helps protect (like other exercise) against heart attack and stroke, burns calories, relieves chronic pain.

Sex is good for our mental health, too, protecting us against depression and stimulating feelings of affection and intimacy. And sexuality is part of our identities, part of what we are.

Sex is part of a life that is not just longer, but happier.

It’s a research report I read recently that’s brought all this to mind. Most of the REVEAL (Revealing Vaginal Effects at Mid-Life) study participants said they weren’t aware of all the effects of menopause—on their vaginal tissues, in particular. Eighty percent of the participants who experienced painful intercourse said they’ve “learned to live with the vulvar and vaginal symptoms… as a normal part of getting older.” And 61 percent of those women felt it was “still taboo” to acknowledge menopause symptoms like painful intercourse.

Live with this for a third of our lives? Give up on—or suffer through—an aspect of who we are and what makes us happy?

I don’t think so. I often use a reading glasses analogy: When, as a part of aging, our eyesight is less acute, we get reading glasses, or a stronger prescription, or bi- or tri-focals. We joke about the type size on menus, and we ask for more light in the restaurant. We don’t give up on seeing! There’s too much of life still before us.

We need to understand the changes that are affecting us. We need to know there are ways to compensate—as with reading glasses—so that we can maintain our sexuality. And we need to let go of the notion that our health and happiness for a third of our lives is somehow a “taboo” subject to talk about—with our partners, our friends, our health care providers.