I’m just gonna say it: the best time to get information about sex after a hysterectomy is before the hysterectomy ever happens.
When a patient come to me with sexual issues after having had a hysterectomy, and she is unclear about what kind of hysterectomy she actually received—what organs were removed or whether she had a laparoscopic or a vaginal procedure, for example—this indicates to me that she may not have sought or received the information she needed in order to make an informed decision.
Whether to have a hysterectomy is a loaded topic these days, so let’s just dive in and get the facts out of the way, shall we?
Hysterectomy is the second most common surgical procedure performed on women after caesarian section. Almost 12 percent of women between 40 and 44 have had one. That number rises to 30 percent by the time you’re 60. About 600,000 procedures are performed every year in the US—the highest rate in the world, although other developed countries also do a lot of hysterectomies.
Most hysterectomies are performed for such benign but bothersome conditions as fibroid growths, endometriosis, heavy bleeding, and vaginal prolapse. Only about 10 percent are done for truly life-threatening conditions such as cancer or a uterine rupture during childbirth.
It’s almost like having a hysterectomy has become a normalized part of growing older as a woman. You get your hair colored, and you have a hysterectomy. That’s just how it goes.
Recently, however, women’s health organizations and other health professionals—as well as women themselves—have been questioning that inevitability and pushing for less radical treatments for benign conditions. These include less invasive treatments, such as having a progestin IUD placed or endometrial ablation for heavy bleeding or uterine artery embolectomy treatments for fibroids. Still, hysterectomy remains the most common go-to for a host of “female troubles.”
Like any surgical procedure, a hysterectomy involves weighing risks and benefits. These are dependent on factors such as age, childbirth history, the size and shape of the uterus, among other considerations.
For example, it might be better for a younger woman with a benign and treatable condition to first try the alternatives to the permanent removal of her uterus because her reproductive organs are still fertile and hormone-producing. Even a woman in perimenopause is still producing hormones with all their good protective benefits to vaginal tissue, heart, and bone.
A post-menopausal woman with an unpleasant uterine prolapse, on the other hand, might be a very good candidate for hysterectomy. This patient’s hormone production has virtually ended and other treatment options aren’t permanent or also involve a surgical procedure.
Sometimes, however, when a woman’s quality of life is so compromised, when she’s in enough pain or bleeding so erratically or profusely, she may be willing to do anything to make it stop. A hysterectomy will make it stop and will often improve both sex and quality of life. But a frank patient/doctor discussion is still critical—so she understands her options and, insofar as possible, what the outcome will be.
So—there are options for treatments of benign conditions such as fibroids or endometriosis. Hysterectomy is invasive and permanent, so it makes sense to explore other options first. But if a hysterectomy seems to be the best approach, you then need to know about the different types of hysterectomy and their outcomes.
This is important, ladies, because how quickly you recover and the effect on your sex life has everything to do with the type of surgery you have and what organs are removed.
We’ll discuss this in a post next week.
You say you haven’t been able to have sex with my husband for about a year. You’ve seen a couple of health care providers: One prescribed an estrogen cream, which wasn’t effective, and the other saw nothing “physically wrong” and, since you’re not yet menopausal, recommended lubricants.
What you describe--a feeling of “tearing” or “burning” at penetration--sounds to me like the condition of vulvodynia (also know as vestibulodynia, provoked vulvodynia/vestibulodynia). The classic description is “burning and tearing” pain with penetration; other descriptors are razor blades or sandpaper-rubbing with penetration. Often, sex leaves women with this condition sore or uncomfortable. Vestibulodynia is an under-recognized cause of painful intercourse, and you’re not alone in receiving ineffective advice.
You express reservations about going to another doctor to talk about this issue. I know it’s difficult to bring up, and it doesn’t feel worth the effort if you don’t get solutions for intimacy. But you do need a provider who is familiar with vestibulodynia and knows the treatment options--because it is treatable and you can be intimate with your husband again.
I recommend finding a provider in your area through the North American Menopause Society (link to their practitioner locator here) or through the International Society of Women’s Sexual Health (ISSWSH) (link to their provider search here). If you choose to use the ISSWSH directory, note that the listing includes therapists as well, so be sure to select a physician who does clinical care and can provide the proper examination and treatment.
Please do follow through to find someone qualified to provide treatment. You don’t have to leave this part of intimacy with your husband behind.
You say that you and your partner use manual and oral stimulation, since you’re no longer able to have intercourse. Your partner requires extended stimulation, and you’re wondering what might help.
Stronvivo is a nutritional supplement developed for men’s cardiovascular health; it’s been found to significantly improve sexual health--because circulation is integral to arousal and orgasm. It is used for both male and female sexual health, improving both desire and function (ability to arouse and orgasm). I’ve had many women report improved ability to orgasm, and the clinical trials report the same for men.
The other factor to consider is medications that may be interfering with orgasm, or hormonal factors, like low testosterone. I’d strongly recommend a conversation with his physician, if he hasn’t already had one, to see whether there are health factors to consider.
You say orgasms are new to you (congratulations!), and, having had the experience, you’re looking to explore it further. You’re not sure your clitoris matches what you’ve read in books.
The external part of the clitoris is the head or glans; the shaft is deep to that. When you touch the clitoris, you’re touching the clitoral head. With arousal, there is usually minimal “engorgement” noted for women. By comparison, think of the penis, whose head doesn’t enlarge all that much when aroused. It’s the penis shaft that enlarges, and for women, the comparable clitoral shaft is internal (here’s a blog post with an illustration, which could be helpful).
A person’s size, weight, and number of pregnancies or childbirths don’t usually alter this part of our anatomy. As we age and hormone levels decrease, the clitoris does diminish in size and there can be skin conditions of the vulva that make the clitoris more “hooded.”
The most consistent, reliable way for most women to experience orgasm is direct clitoral stimulation (for others it’s vaginal at the “G spot”), and a vibrator tends to provide that for most women. But “most women” isn’t “every woman,” so you might try warming products, which can be helpful by providing stimulation to bring more blood supply to the area.
I wish there were a single route to experiencing orgasm--or maybe I don’t. There’s something nice about it being individual and unpredictable. Continuing the pursuit is fulfilling and, I hope, ultimately satisfying, too!
You say you’re hoping to enjoy intercourse again after a five-year hiatus, but that you experienced some discomfort with your last gynecological exam. The prescriptions offered to you (which I assume were localized estrogen) are not in your budget, so you’re wondering about other options.
A vaginal moisturizer, used regularly, can help you regain some tissue elasticity. Any of the moisturizers we offer might be an option for you; they’re intended to be used regularly, from daily to several times a week.
Along with thinner and fragile tissues, in menopause, without estrogen and without sexual activity, the vagina will become more narrow and shortened. You may need the gentle stretching of dilators to help restore vaginal capacity.
I’m hopeful that, with some effort and regular attention, you can restore vaginal health to resume pleasurable intercourse!
Resolutions are easy to make and hard to keep (most people don’t). However, as we mentioned before, certain psychological tricks can increase your chances for success, and sheer persistence is one of them.
In the spirit of successful resolutions, I propose devoting January (yes, the whole month) to specific health-related resolutions. In fact, each one focuses on an often neglected body part that is critical to good sex and/or well-being.
First up? The pelvic floor.
You might not think much about your pelvic floor, but it affects you every single day. That surprising leakage after your firstborn child? That need to pee every half hour now that you’re post-menopausal? The more frequent UTIs? The slack “vaginal embrace” during sex? That really annoying pelvic organ prolapse that’s causing all manner of issues?
All these annoyances (and more) are related to the muscles in your pelvic floor. That’s why we write about pelvic floor health and doing kegels so much on MiddlesexMD. That’s why a healthy pelvic floor is part of our recipe. That’s why we have products to help you do those kegels right. It’s all because a healthy pelvic floor is so darned critical to our quality of life, especially as we get older and lose muscle tone and elasticity.
While many lifestyle improvements—losing weight, not smoking—will coincidentally improve the pelvic floor, they aren’t the stuff of resolutions that are easy to keep. Kegels, on the other hand, are specific, countable, time-limited, and realistic—all the elements of a solid, successful program.
And now, they can be fun! (Another element of success.)
A new smartphone app combined with a high-tech vaginal tool was recently launched on the crowdfunding website Indiegogo. Perifit is an exercise tracker/trainer for your pelvic floor. It’s comprised of a flexible, bulbous, silicone tool that goes in your vagina and sends low-energy Bluetooth signals to an app that is downloaded onto your smartphone, tablet, or laptop.
If you’re successfully tightening your pelvic floor, a butterfly stays afloat on your device. The tighter you squeeze, the higher it flies. Not only will you know if you’re tightening correctly, but the tool also measures both deep and shallow muscles contractions as well as their effectiveness against four parameters: force, endurance, reflex, and agility. You also get to choose among several training programs targeted toward specific issues, such as different types of incontinence or post-childbirth trauma.
The program isn’t cheap, and it’s also new, but it’s a hugely fun concept and casts the notion of doing kegels in a refreshingly different light. If nothing else, watch the video with the adorable baby and draw comfort from the fact that women of all ages are working on their pelvic floor.
Like any workout, developing pelvic floor muscle takes time and consistency. Whether your success with this program depends on a butterfly video or vaginal weights or your own self-discipline, you have choices among several tools, one of which might align well with your personality.
The last element to a successful resolution is persistence. Of course you’ll forget or skip days or get lazy. The secret is to pick up where you left off and keep on going. Set up a realistic, measurable program. Healthline recommends holding a kegel for a 3 seconds; releasing for 3 seconds and working up to a 10-second hold. Three sets of 10 ten-second reps a day is a good goal.
Developing pelvic floor strength isn’t as obvious or satisfying as working on tanktop arms or a bikini belly (if that’s even possible anymore), but it is arguably more important. Avoiding or reducing incontinence, UTIs, and pelvic organ prolapse while increasing sensation and vaginal strength for better sex is nothing to sneeze at.
We have a new product in the house, and our team is pretty excited about it. I’m asking some of my patients to work with it as well as trying it myself, and I’m hoping to see exactly the same success with us as the manufacturer has been seeing in their studies. The studies you can see here, in the Journal of Sexual Medicine.
This product, called Stronvivo, is a supplement for women and men.
And, before you worry about a doctor pushing Supplements, please hold on a minute. Good science backs this supplement up.
Stronvivo contains a stack of amino acids and minerals that are all essential to human life, but particularly helpful for supporting endothelial health—that is, strong blood vessels. These are amino acids and minerals that at our age we might not be easily getting or producing through our diets, metabolisms, or normal organ function.
And what are healthy blood vessels good for? They are great for the happy working of sexual organs. They are what make those organs go. Hers and his and theirs.
But, bonus! These same elements in these supplements are great for helping support the circulation of sexual hormones! Win-win! And especially a win for women who, because of cancer risk or preference, want to support what hormonal production their bodies can manage post-menopause without the aid of hormone replacement. This is a great offering for me as a physician. I love having a non-hormonal alternative I can present to my post-menopausal patients, and their partners!
And it plays out in the research of this formulation. The company tested their Informed-Choice, all-natural, US-manufactured product with women and men over 40 who have arousal issues. The results showed clinical improvement of the health of the endothelium, stimulation of nitric oxide production, reduction of platelet aggregation and adhesion, improved circulation, improved hormone production in the test subjects.
Clinical evaluations used the FSFI (Female Sexual Function Index), the PHQ-9 (Patient Health Questionnaire), the IIEF (International Index of Erectile Function, and the ADAM (Androgen Deficiency in the Aging Male) to measure female and male patients over 90 days. The women showed improvement in desire, arousal, lubrication, orgasm, satisfaction, and pain. The men improved in androgen levels and overall satisfaction.
And both women and men had improvement in mood, with less depression.
To understand the full potential, 90 days’ use is recommended for women; men may see full benefit after as little as 30 days.
Personally, I like the idea of a nutritional supplement that couples take together. It represents a kind of shared commitment to lovemaking and holding on to one another.
Also, from a purely medical point of view, keeping the smaller blood vessels of our sexual organs happy will keep your larger vessels happy. And that will keep your whole body working better through time.
And that makes this doctor very happy. If we’ve convinced you to give Stronvivo a try, you can order it here.
I’ve got much to catch up on, study up on, and share with you from my trip to the North American Menopause Society (NAMS) annual meeting a couple of weeks ago. It was a whirlwind of great talks, and such a marvelous time to catch up with colleagues who are doing wonderful work.
One of my all-time favorite people, Dr. Susan Kellogg-Spadt, who’s been a medical advisor here at MiddlesexMD, spoke at the conference! She was fantastic, of course.
She’s a nationally recognized expert in pelvic and vulvar pain and the Director of Female Medicine at the Bryn Mawr office of Academic Urology at the Center for Pelvic Medicine, in Rosemont, Pennsylvania. She treats patients throughout the United States as a vulvar specialist, sexual dysfunction clinician and therapist.
At her NAMS talk, Susan talked specifically about the sexual needs of menopausal women, and in some detail. We gain so much from having her in our field! But without further, um… gushing? Here are Susan’s top clinical pearls for our sexual health and happiness:
Add moisture daily. If we use a water-based, bioadhesive lubricant several times a week, regardless of sexual frequency, we can get a lot more comfort and satisfaction with sex and just make it easier to have an orgasm whenever we want to.
Nourish yourself. A Mediterranean diet has been shown to promote sexual function, (and, we just learned, perhaps lower breast cancer risk). And regular exercise improves mood and overall health, both of which contribute to better sex.
Talk it out. When we use “I” language to talk with our partners about sex honestly and in a non-accusatory way, we increase the chances of sexual success. Your NAMS doctor or therapist can help provide the vocabulary and communication tips.
Prioritize pleasure. Don’t wait for intimate time to just happen. Even a 20-minute block of time, scheduled weekly, for touching and intimate conversation can clear the way to better sex. Putting it on your checklist may seem like a cold thing to do, but trust us, it gets hotter with practice.
Mindfulness matters. Reading or watching even the softest erotica, being mindful of erotic thoughts as they occur, and focusing on sensation rather than distractions during arousal are all important. All mindfulness training can contribute to your ability to stay in the moment during your most intimate moments.
Intensity, baby. After menopause, many women need more intense stimulation to reach orgasm. Consider introducing vibrators into sex play. The term, “Doctor’s orders!” can be very useful here. You have our permission to use it.
Do try. Just opening up and talking about sex problems, and finding what can still be sexual successes, shows that a woman is committed to her partner, and taking action shows her level of care and concern for the relationship. Mutual affection, honest attempts at exploring what is possible, comfortable, what still feels good, does amazing things for a relationship.
My car’s license plate reads “HOTFLAS.” I take it for granted, until someone rolls down his window to talk to me at a stop sign.
“Hey, I like your license plate,” he says. “You must be about 50. Wow, my wife is going through that. It’s really tough. It’s been a real challenge.”
Only a few days later, I was meeting with a colleague from a nonprofit for whom I volunteer. “Remind me what you do,” he said. It took about half a sentence from me (“I’m a doctor specializing in menopause care…”) to strike a nerve with him. “It’s like a stranger is living in my house,” he said, of his wife’s journey through menopause.
It’s Menopause Awareness Month. These men—among so many others who regularly cross my path—are aware of menopause. Now. I think it’s safe to say that the experience has taken them—and their wives—somewhat by surprise. I can’t think of another medical condition that affects so many of us—directly and indirectly—yet about which we have so little advance education.
Six thousand American women become menopausal every day (defined as not having menstruated for a year). In the U.S., the average age of menopause is 51; that’s the age the youngest of the Baby Boomers are now. We have the highest proportion of menopausal women in our population we’ve ever had—and may ever have again.
And yet, women I meet in all areas of my life—and the men who are living with them—are surprised by the range of effects from the change in estrogen in their systems. While lots of jokes (and T-shirts) circulate about hot flashes, women don’t realize that they may also have
About half of women have pain with intercourse five years after menopause. For whatever reason, many women don’t associate that symptom with menopause. Too many of us think it’s just “what happens.” Too many of our doctors don’t ask about our sex lives, so women don’t tell about their experiences. While there are a range of treatments—both over the counter and prescription—that would help, too many of us are unaware of them.
Avoiding the topic doesn’t make menopause go away. I’ll keep talking—to patients, to colleagues, to men and women on the street. I encourage you to learn everything you can, pay attention to your own health, and to join the conversation! We midlife women are indispensable resources to our families, our companies, our communities. We deserve to have this natural phase of our lives understood!
We're always trying to give you food for thought; this time we want to encourage you to think about the relationship between food and sex. It’s pretty straightforward: Eating healthy foods leads to feeling healthy and feeling healthy both increases the likelihood that you’ll be interested in sex—not to mention that you’ll enjoy it.
There’s no easier time to eat healthfully that than harvest season, when fresh fruits and vegetables are plentiful. If you plan ahead, you can turn your quest for healthy eating into a fun activity that brings the two of you closer.
Take some time to choose a menu together, or, if your partner isn’t interested in that step, at least get buy-in for the menu that you’ve chosen. As you and your beloved stroll through the farmer’s market (or grocery store), talk about the associations you each have with fresh foods. In learning why your partner hates blueberries or loves Brussels sprouts, you might hear a childhood story that gives you new insight.
While any fresh fruit or vegetable is good for you, you may want to seek out specific ones. The folic acid in asparagus, for example, increases histamines, which are important to sex drive. Meanwhile, watermelon contains L-citrulline, an amino acid that increases blood flow to sex organs. Peaches do the same thing. And cold-water fish like salmon, anchovies, and oysters are high in omega-3, which improves everything from mood to memory. The avocado has two things going for it: its suggestive shape and the folic acid it contains.
When you have all the ingredients and have found your way home, the real fun begins: You cook together—in more ways than one.