Resolve to Speak Up!

I was struck by this sentence in a report on research with women aged 45 to 65 experiencing menopause: “As a generation, they have yet to develop a voice for this situation, and many remain silent rather than proactively seeing help.”

Really? We are the generation who, in high school, bought Our Bodies, Ourselves to better understand menstruation and sex. We pushed the boundaries to study science, go to medical school, become executives, compete for construction jobs, run our own businesses. We bought Marlo Thomas’s “Free to Be You and Me” for our kids.

But in my own experience as a physician, I see evidence that it’s true. When my practice included women of all ages, patients came in ready to talk in detail about physical symptoms—and emotional effects—related to pregnancy or fertility or uncooperative or uncomfortable periods. I don’t recall as many conversations about symptoms of menopause, especially as they related to sexuality.

In the last few years, since I’ve focused my practice on mid-life women, those who come to see me are ready to talk. This may have encouraged me to think we’ve made more progress than we have; this “REVEAL” (Revealing Vaginal Effecs at Mid-Life) study is a useful reality check. This research found that 41 percent of postmenopausal women had not talked to anyone about their sexual health in the previous year. Just over a third had talked to a health care provider; fewer—30 percent—had spoken to their partner or significant other.

The oldest women in the study—60 to 65—were least likely to have spoken to anyone at all. The younger women—45 to 49—were more likely to have spoken to someone: health care providers, partners, and then female friends.

Why does any of this matter? Consider the other findings of this research:

  • While almost all of the women surveyed were familiar with hot flashes as a symptom of menopause, fewer than half were aware that vulvar/vaginal pain was another symptom.
  • A quarter of those surveyed experienced pain during sex; most of those women still have sex—in spite of the discomfort—at least once a month.
  • The majority—80 percent—of the women who experienced pain during sex assumed it was a “normal part of getting older.”

That’s a whole lot of women who aren’t aware that sex can still be pleasurable and pain-free, even after menopause. And it’s a whole lot of women who won’t even broach the topic with their health care providers, because they assume that nothing can be done.

So! Clearly, it’s up to you! I imagine a whole lot of conversations between best women friends, women and their partners, sisters… and, for the sake of the next generation, between us and our daughters.

There are symptoms of menopause beyond hot flashes, night sweats, and mood swings. Decreasing hormone levels affect our vaginal and genital tissues, but they don’t spell the end of sexuality—or comfortable intercourse. There are things any woman can do to restore or preserve her sexual health, and we need to talk about them!

Sounds like a great resolution for 2011.

One Test Where Grades Don’t Count

Many of the women I see in my office would like a black and white answer: Where, exactly, are they on the path to menopause? Unfortunately, I can’t really give them a solid answer, and here’s why.

Perimenopause—that period (no pun intended!) between regular menstruation and menopause—isn’t a steady progression. It’s more like two steps forward, one step back. Sometimes, one step forward, two steps back. You may have some signs along the way, like moodiness, insomnia, irregular periods, hot flashes, lack of interest in sex, or vaginal dryness.

Sometimes FSH tests are used to help fill in the picture, providing one more data point. I don’t often recommend these tests, though, because although the tests are accurate at that moment on that day, they can be wildly misleading—unless you’re not yet in perimenopause (in which case the test can point to other issues) or you’re in menopause—which you already know because you’re not menstruating.

Here’s what’s happening with FSH (follicle stimulating hormone): The pituitary gland sends out FSH to tell the ovaries to make estrogen, which helps eggs grow (stimulating follicles!) and thickens the uterine lining. The pituitary gland acts like a thermostat: if it senses estrogen production is low, it “kicks on” and releases more FSH.

But as I said, the path to menopause is not a straight one; most women have erratic periods before menopause. So even if you are 52 and have every other symptom of perimenopause, if you take the test during the one time in six months you happened to ovulate, your FSH levels would suggest you’re not menopausal. Lifestyle-related factors like stress and smoking also affect FSH levels, making them even less helpful.

Typical Hormone FluctuationsCheck out the graphic to see the kind of unpredictability that’s typical. The first graph shows regular hormonal fluctuation when you’re having regular cycles. The second graph shows how wildly all four hormones may vary over six months. The last graph shows that a consistently high level of FSH accompanies menopause. But, again, if you’re not having periods, you don’t need a hormone test—either from a doctor or an at-home saliva test—to tell you you’re menopausal. (If, by the way, you’ve had a hysterectomy, endometrial ablation, or another procedure that’s eliminated periods but you still have ovaries, you have the same unpredictability in hormone levels. Charting your symptoms for a few months may be the most helpful approach. 

I understand that the ambiguity of perimenopause bothers some women. As a physician with a pretty good understanding of all the pieces at play, maybe I find it too easy to recommend that women tune in to their bodies and take it a month at a time. How have you found peace with the changes that are part of The Change?

This Lube Is My Lube

When we were assembling our product collection, the MiddlesexMD team spent a fair amount of time researching personal lubricants. Some of this research was straightforward: We knew safety came first, of course. We knew glycerin is a nice ingredient for some women, but for others it encourages yeast infections. Some of us (in particular women who want the lube to last as long as 45 minutes without reapplying) like silicone-based lubes, but they don’t work for women who use silicone-based massagers or vibrators. For some of us a thicker gel is more comfortable; others find a slippery liquid to be just right.

We did our homework. We were thorough. We assembled a variety that covered these bases, as well as preferences for organic ingredients and sensitivities to others. And then, that poor product team: If you’ve looked at our product catalog, you know we try to give a little extra information, a bit about why we as women of a certain age like the products we offer, what to look out for, who might be especially interested. The product team felt obliged to provide some pointers on smell, feel, and, yes, taste—for each of the lubricants.

So the team devoted an afternoon to exploring the options. They learned a lot. There were one or two, for example, that everyone agreed they’d rather not taste again. There was one in particular that a majority thought smelled pretty good. One lube seemed to moisturize the skin really well. The truly important thing the team learned was that Diet Coke could “cleanse the palate” between lubes.

That experience testing lubes made us think. If we hadn’t had all the samples on hand, we never could have tried so many so quickly. Since none of the quality lubes is cheap, how does the average woman find the one she likes best? Without investing a fortune and struggling with her conscience about dumping the nearly full bottles she doesn’t like? Do women put up with one they don’t like—that doesn’t last or smell good or feel good or… er… taste good—because it’s too much of an investment to find a fave?

And that’s how we came up with the Personal Lubricant Selection Kit. We send you trial-size amounts of various types of lubricants and a card you can redeem for a full-size bottle of your favorite. Easy.

And you know what? That Kit has been one of our most popular products since we launched our store. It’s gotten a lot of attention at the conferences for health care providers we’ve been at lately. And we’ve gotten quite a few cards back from women who’ve conducted their own tests.

You might say all these women agree to disagree: There is no single favorite. There’s not even a trend. Not for which lubes feel best, not for which lubes smell best—not even for which lubes taste awful!

This is good news for us, of course: It means we really did have a useful idea when we put that Selection Kit together. And any day, I’m confident, the product testers will begin to forget that long afternoon with the Diet Coke chasers… and when they’ve forgotten, maybe I’ll tell them just how individual these preferences are—and how many taste tests they could have skipped.

Warming Up to Foreplay

I’m a recreational runner, and before a run, I always spend a few minutes warming up. I’ll run in place and do some stretches, especially of my calves and ankles. Experts no longer say this is a must, but I do it anyway because I know that as I’ve grown older, I have tighter muscles and less range of motion in my joints. And I’ve learned that if I exercise and end up hurting, I’ll be more likely to postpone my next outing.

This cycle can also be true of sex. If you rush past the warm-up—foreplay—you may not have enough lubrication to make penetration comfortable. If sex hurts, you’re less likely to initiate it or to respond to your partner. The more time that passes without having sex, the more difficult it is.

Many couples have a long habit of foreplay, but If the women I talk to are representative of the larger population (and I believe they are), men don’t always get the connection. They are happy to skip the foreplay and sprint to the finish line. Early in the relationship, that might work even for women, who are more sexually complex than men, because excitement is high all the way around and it’s easier to get aroused. It might even fly during the “thirsty thirties,” when women’s sexuality peaks.

But during menopause and after, hormones work against us. Estrogen declines, vaginal tissues become thinner and more fragile, and circulation to those tissues decreases. The less stimulation your vagina receives—from sex with a partner or your own self-care—the faster those changes happen.We’re not kidding when we say, “use it or lose it!”

So after menopause, we need more to warm up. More real intimacy, more talk, more titillation. In short, more time.  The stakes are higher now. If we don’t warm up, it hurts. If it hurts, we don’t want it. If we avoid it for too long, it’s more and more difficult to have it. If any of this sounds familiar, it’s probably time to talk about it.

Because a little foreplay has gone a long way in the past, your partner might be puzzled when you suggest your lovemaking include more foreplay. He might worry he’s losing his sexual prowess. This is a great opportunity to explain how changing hormones affect your response to sex. If there’s something you’ve secretly been longing to suggest to him lo these many years, you can slip that into the discussion, too. It’s never too late for your partner to learn, and telling him what you need and why is a great first step.

How about you? Have you been able to change the patterns of sex with your partner? How did you approach it? How did your partner respond? We’d love to hear!

Q: Why did I have pain and tightness during intercourse?

In menopause, in the absence of estrogen, the vagina narrows and becomes more thin and fragile. Even when you are lubricated enough, the tissues have likely lost elasticity and can’t comfortably stretch with intercourse. Some light bleeding represents the "trauma" to those tissues and usually comes from near the opening of the vagina or the vaginal tissues themselves.

Using a vaginal moisturizer (like Yes, Replens, or KY Luiqibeads) would almost certainly help. It may also beneficial to use dilators to try to get back more caliber or capacity (dilators literally stretch the tissues gradually). You might also talk to your health care provider about vaginal estrogen, also known as localized estrogen, which may be of benefit to you in restoring elasticity.

Don't give up! You can be comfortable again.

Q: Any suggestions for overcoming lack of desire and pain during sex?

The first thing I try to do with women who have both of these issues is to make sex comfortable. It is pretty hard to be interested in intercourse when you know it is going to lead to pain.

You might consider vaginal estrogen--estrogen that is 'localized' rather than 'systemic' and is delivered only to the vagina. This would require a prescription product. Or you need to commit to using a vaginal moisturizer consistently; this reintroduces moisture to the vagina on an ongoing basis.

Once sex is comfortable, then approach the issue of desire, which admittedly, is difficult. Yours might be a situation in which to consider using testosterone or buproprion, an antidepressant that can have the side effect of increasing desire. Engaging mindfulness and choosing sex is important to the sexual relationship. I review Basson’s research with patients, and remind them that desire does not play as big a role in women’s sexuality at this stage of life, so being intentional and choosing to engage is often necessary.

Find a provider you trust to talk through some of these issues and begin to explore options.

Q: I've had a hysterectomy; does my vagina still clean itself?

Fortunately, the vagina is self-cleansing; it requires very little attention. The cells on the surface of the vagina naturally regenerate or ‘turn over’ on an ongoing basis. After intercourse, semen deposited in the vagina coagulates and then slowly liquefies again and is slowly secreted.

The top of the vagina is called the vaginal cuff when the cervix has been removed as a part of a hysterectomy. Not having a cervix doesn’t change that cleansing mechanism. Douching is disruptive to this natural cleansing process, disrupting the natural, healthy environment created by ‘good bacteria’ that belong there. In this case, less is best!

If you've had your ovaries removed or are naturally menopausal, the absence of estrogen means your vagina can benefit from a moisturizer placed inside the vagina. We offer several great choices.

Q: How do I treat dryness and vulvodynia while taking Tamoxifen?

The most important thing is usually to re-estrogenize the vagina—with localized, not systemic estrogen. I haven’t seen a single oncologist not agree to allow breast cancer patients to use this. There are a couple of really low-dose estrogen products to use in the vagina; the estrogen is not absorbed outside of that area. Vulvodynia occasionally benefits from the localized estrogen too, or there are some topical options.

A thorough and detailed pelvic exam could help to determine where the pain is arising (vulva, introitus, vagina, pelvic floor muscles, and/or vaginal cuff). Each of these has a different solution, or maybe a combination of options.

A lubricant will help somewhat with sex, but a moisturizer (like Yes) is more important for prevention and long-term preservation (vaginal estrogen can accomplish this, too). Some of my patients use a topical anesthetic in the area. If you have lost some caliber of the vagina—some narrowing, dilators can help restore that. Some women with longstanding pain with intercourse develop vaginismus, in which the involuntary muscles of the vagina go into spasm.

Don’t stop trying! Usually we can restore comfort!

Q: Why are orgasms different and more elusive?



If you’ve missed periods, you are perimenopausal. It’s likely that you are experiencing symptoms of less circulating estrogen. Hot flashes are the most common symptom from that, but the way we experience sex changes too.  Medications taken for other conditions can compound the issue.

It is not unusual to for orgasms to differ in sensation as a reflection of differing stimulation. Using a warming lubricant may help with arousal, or considering localized (vaginal) estrogen could also help. To help with arousal with a partner, you can introduce new techniques or bonding behaviors. With a partner or on your own, you might experiment with erotica—either books or DVDs.  You may want to use a vibrator, or if you've been using one and it doesn't seem to be helping any more, consider one that offers more stimulation.  

Welcome to this new phase of sexual life!

Q: Is Vagifem good for dryness?



Vagifem is a low-dose ‘localized’ estrogen. It is delivering estrogen to the vagina and adjacent tissues, but not to areas outside of this area (that's why it's called 'localized' vs. 'systemic').  This is a great choice for maintaining vaginal health, since estrogens improve blood supply to the area.

By the way, Vagifem has just come out with a lower dose — 10 mcg as opposed to the typical 25 mcg — that seems to work just as well. There is another prescription alternative:  a low-dose ring and cream to deliver estrogen to the area.

An over-the-counter option could be vaginal moisturizers used consistently. Moisturizers don’t improve blood supply, but they do work to keep the vagina moist and supple. You might also benefit from a lubricant during sex.