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.

Dilators: A Simple and Effective Stretch

Even though vaginal dilators have been around for decades, they still elicit lots of attention and a few quizzical looks even from healthcare professionals whenever we display our wares at medical conferences. My patients sometimes have questions, too, and we get phoned-in and emailed questions here at MiddlesexMD.

Dilators are one of the most straightforward medical devices you’ll run across. They are a set of tubes that gradually increase in diameter from about a half-inch to about an inch and a half. They are usually made of high-quality plastic, but may also be made of silicone, which gives them a softer, more flesh-like quality. Both types are washable with soap and water. Dilators are used to increase vaginal “patency,”—its capacity and ability to accommodate the things that vaginas are made to do, like a speculum, a baby, a penis—some pretty important stuff, in other words.

Dilators are used to:

  • Prevent scar tissue from forming after some cancers or pelvic radiation therapy.
  • Increase vaginal capacity and length after certain procedures, such as a total hysterectomy.
  • Maintain vaginal capacity during times when sex isn’t an option for whatever reason.
  • Improve vaginal capacity after a long time without sex (remember the old use it or lose it adage).
  • Help to address vaginal shortening and tightening due to hormonal changes of menopause.
  • Treat conditions, such as vaginismus, that make penetration difficult.

Since some vaginal conditions might require additional treatment, such as localized estrogen or muscle relaxants, you should always discuss any vaginal pain or change in your ability to have sex with your doctor, as well as how you might benefit from using dilators. From there, if it’s simply a matter of conditioning or maintenance, our shop has a selection of high-quality plastic and silicone dilators.

I recommend any of these sets. Choose the features and sizes that appeal to you. The first set that we found and offered remains a favorite. It’s available with five or seven dilators, depending on your starting point, and the straight, solid cylinders are easy to handle and clean.

The silicone kit is firm yet flexible with a softer touch. (Bright colors don’t hurt, either.) Be aware that silicone lubes will degrade the surface of these dilators, so use them only with water-based lubricants.

The Amielle kit is our high-quality, good-value choice. This set of five dilators is made of medical-grade plastic and includes a detachable handle that might make insertion easier.

Increasing vaginal capacity takes patience—often several months. For maintenance, you may need to use dilators regularly until you’re having sex regularly. The goal is to accommodate your partner’s penis (or your doctor’s speculum) comfortably and without pain. It’s a worthy goal, so accept that you’re in it for the long haul.

To use dilators:

  • Start with a warm bath to soften tissues and relax your pelvic floor muscles (along with everything else).
  • Find a comfortable and private place and lie down on your back, legs bent at a 45-degree angle and shoulder-width apart.
  • Consciously relax all your muscles, from head to toe. Do a mental scan for areas of tension around your eyes, brows, or anywhere else. Focus on breathing in; breathing out.
  • Begin with the smallest dilator and slather it with high-quality, water-based lubricant. (Not petroleum jelly or any kind of oil.) Generously lube your vaginal entrance as well.
  • Gently insert the dilator until you meet resistance. Pause. Breathe. Practice kegel exercises. Insert it a little farther if you can do this without discomfort. The dilator should fit snugly but without pain.
  • Keep it in place for twenty or thirty minutes. Watch TV or listen to a podcast or your playlist. Practice kegels.
  • You can try rotating it in place or moving it in a circular motion around the vaginal entrance or gently moving it in and out.
  • Clean with soap and water. Towel dry.
  • Move to the next size when you can comfortably insert the smaller one.
  • Do this 3-4 times per week or every other day.

You may bleed a little at first. This is normal. But if you soak a sanitary napkin or experience frequent bleeding, this is not normal. Stop using the dilator and call your doctor.

I like dilators because they’re both simple and effective. Granted, taking a pill is easier, but there are no pills that treat vaginal patency as such. If you stick to the regimen, dilators are very effective in both reconditioning the vagina and in maintaining elasticity during fallow sexual periods.

 

Sex and Your Hysterectomy: Getting Sexy Back

Recently, we’ve been discussing the reasons to have (or not to have) a hysterectomy and the various surgical options—all very important information to have before you decide to have the procedure.

Now let’s talk about what happens after the surgery. Specifically, what might happen to your sex life.

Usually, your doctor will tell you to wait about four to six weeks before having sex, depending on the type of procedure you had. You might want to clarify with your doctor exactly what he or she means by “sex.” Usually, that means vaginal penetration. So ask if oral sex is okay. How about using a vibrator or a hand?

When you’re ready for intercourse, you’ll want to start gently—lots of lube and gentle penetration. If the cervix was removed, it may take time for the top of the vagina (the “vaginal cuff”) to heal. Penetration may feel differently for a while. (Here’s a good metaphor for the process.)   

Sometimes, emotional healing has to happen as well. After all, hysterectomy is the surgical end to childbearing. For some, depending on the reason for the hysterectomy, this is a relief; for others, it’s a significant and sometimes difficult transition. If you are overwhelmed by emotion or even depression, give yourself some time and space to heal. You may also need to seek out a listening ear or professional counselor to regain balance.

If your ovaries were removed, and you haven’t yet gone through menopause, or even if you’re in perimenopause, be prepared for the possibility of significant emotional and physical change. With the removal of your ovaries, hormone production suddenly stops, and you’re now in surgically induced menopause. This requires some preparation ahead of time and some patience and therapy after the procedure.

The good news is that, for most women, sex tends to be unchanged and is sometimes better. The parts necessary for orgasm are still intact, and the issues that may have caused the trouble in the first place (pain or bleeding) are gone. “Most women tell me that there is no change in the way they feel orgasm, and they are able to enjoy sex more since they don't have their original problem to interfere with sex,” writes Dr. Paul Indman in this article.

This opinion is supported by several studies confirming that, for most women, sex is the same or better after a hysterectomy. In a small study of 104 women, researchers determined that the best predictor of the quality of sex after a hysterectomy was the quality of sex before the procedure.

Despite the research, some women say that sex just isn’t the same. They report weaker orgasms and less sensation, loss of libido, and difficulty with arousal. Therapies can help—hormone replacement, localized estrogen, lubes and moisturizers—but they can’t replace nature.

Furthermore, although the vast majority of women recover well, a hysterectomy is still a surgical procedure with all the attendant risks and uncertainties. Unexpected outcomes happen—nerves may be damaged; prolapse or fistula may occur. The long-term effect of removing significant abdominal organs is still poorly understood.

With that in mind, some tips for approaching this, or any, surgery might be:

  • Try the most conservative treatments first. Fibroids, heavy bleeding, endometriosis can be treated with less invasive methods. Start there. A hysterectomy isn’t the first line of defense.
  • Opt for the most conservative surgery. If a hysterectomy is the best choice, make sure you understand your options. The least invasive surgical options (vaginal or laparoscopic) simply have better outcomes. If there’s no good reason to remove your ovaries, ask about keeping them.
  • Do your homework and line up your resources. Make sure you and your partner understand what’s happening and be prepared for a time of adjustment afterward.

Several years ago, an acquaintance had a total hysterectomy that included the removal of her ovaries. She was post-menopausal at the time, but sex was still very important to her and her husband. She was worried about the effect her hysterectomy would have on their sex life and discussed it with her doctor.

Recently she told me that there had indeed been a period of transition after her hysterectomy, but that over time, she had regained her former sensation, including the deep, pleasurable orgasms she had been accustomed to.

“I don’t know how it happened,” she told me. “I just worked from the memory of what sex had been before my surgery and focused on regaining that. And I did.”

Everyone’s experience is unique. It’s impossible to predict with utter certainty how an individual will respond to any surgical procedure. With a good medical team, good information, and a supportive partner, you’ve tilted the odds strongly in your favor.

 

Fingers Crossed, Minds Open

This week Thursday, there’s a dry-sounding meeting that is a big event on an issue of enormous interest to a relatively small number of us. I’m talking about the joint meeting of the Bone, Reproductive and Urologic Drugs Advisory Committee and the Drug Safety and Risk Management Advisory Committee of the FDA. Snoozing yet?

This meeting will hear presentations about Flibanserin, a drug developed to address loss of sexual desire, which is a real issue for some women. I’ve been following the prospects for Flibanserin (and other pharmaceuticals) for some time, as you may know if you’ve followed this blog. There’s been controversy—in medical, regulatory, and sociological circles. Some said the original studies were inconclusive. Some said the side effects were too significant. Others said that loss of desire isn’t an issue at all—that, variously, couples therapy, a romantic dinner, or more chocolate was the answer.

As a physician, I have conversations with women about their sex lives every day. Some women are clear about relationships that are no longer satisfying. Some have emotional issues—some from past sexual trauma, others from life’s over-abundance of stress—that affect their attitudes toward intimacy. Some have physical symptoms of discomfort or pain or loss of sensation that we can address.

But there are some who have simply lost desire. They love their partners, they have no physical symptoms or obstacles to overcome, they have no complications in their lives that would explain away the change. The overwhelming emotion they share with me is sadness. They are experiencing a loss. And my overwhelming response is frustration. Because as many options—over the counter and by prescription—as I have for vaginal dryness and pain and loss of sensation and even depression, I have no options for treating loss of desire.

Here are the things I hope the members of the advisory committees are keeping in mind when they hear the presentations this Thursday:

  • Loss of desire—for insurance code purposes, Hypoactive Sexual Desire Disorder (HSDD)—is real. Women and their doctors are smart enough to figure out when there’s another issue of physical or emotional health. And one in 10 women has HSDD.
  • Women are as deserving as men of treatment for conditions that affect their quality of life. There are 26 drugs for male sexual dysfunctions; surely a healthy and satisfying sex life can be as important to women as to men.
  • Women and their doctors are capable of deciding for themselves what trade-offs they’d like to make with their health. We’re already doing it with hormone therapy; for some of us, the benefits to our overall health and quality of life outweigh potential risks or side effects.
  • No blanket rules are required. Whatever treatments are available will be choices, subject to the insight of health care providers and individual patients’ health histories, values, and priorities. We’re hungry for options.

And I recognize that this week’s meeting is only one step down what has already been a long road. The advisory committees will make recommendations, but they won’t make a decision. That’s the work of another day. The pharmaceutical industry has to retain interest and commitment actually to bring drugs to market. Health care providers need to educate themselves and their patients about the options and the trade-offs.

So it’s a long road, still. Please, let’s just take one step. With open minds and fingers crossed.

The Progress We’re Making

Birthdays are a useful thing—although it’s increasingly easier to celebrate them for our children (or grandchildren) than for ourselves. Here at MiddlesexMD, we’re celebrating a milestone: It was five years ago this month that we launched our website. While I’ve been practicing medicine for much longer (did I say it’s not easy to celebrate every milestone?), this marks five years of encouraging women to learn about and take charge of their sexual health throughout their lives.There are a number of ways to measure how far we’ve come, like marking our children’s height on a chart. The first that comes to mind is the number of women who’ve been in touch.

We’ve been in contact with hundreds of thousands of women (and men who love them) from 209 countries. Many have thanked us for solving a specific problem, or for simply providing some hope and a path to follow.

We’ve talked to hundreds of women in person, too, at medical conferences. Nurse practitioners and other health care providers have said how grateful they are to have a resource for patients and, because many of them are women, have shared personal stories, too.

As a physician, I have more options available to me than I did five years ago. Osphena comes to mind as a treatment for vaginal and vulvar pain. And while localized estrogen products have been on the market for a while, I’ve noticed more advertisements for them. While too much advertising—especially of pharmaceuticals—can sometimes just be noise, I see the ads as an increase in conversation about women’s sexual health. And that’s a good thing.

I’m hopeful about increased conversation at the FDA, too. Last fall I attended meetings to discuss how the agency reviewed and set priorities for drugs to treat women’s sexual health challenges. It’s been rewarding to join with colleagues in Even the Score, a campaign for women’s sexual health equity. In March, eleven members of Congress signed a letter to the commissioner of the FDA, expressing the firm belief that “equitable access to health care should be a fundamental right” and noting the disparity between the number of FDA-approved drugs for male sexual dysfunction (26) and female sexual dysfunction (0).

Yes You Can by Dr. Barb DePreeIt will take some time for new treatments to make their way through development, testing, and FDA approval. In the meantime, I’m also happy to note more books (including my own) and websites offering information, encouragement, and community to women as they navigate midlife and beyond. 

I hope you’re talking, too—to your partner, your friends, your sisters, and your health care provider. When we share our experiences, we feel less alone. And we can also learn from each other about what’s happening and what works to keep us vital and engaged. Because we know that even at—especially at—midlife and beyond, we’ve still got it!

April 15, 2015

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orgasm ›   Q&A ›   sexual intimacy ›   SSRI ›  


Q: Which of my medications is inhibiting my orgasm?

You say you’re taking daily doses of Wellbutrin and Effexor. Effexor is the likely culprit, since Wellbutrin is actually “pro-sexual.”  Wellbutrin increases dopamine, a neurotransmitter beneficial for sex; Effexor increases serotonin, a neurotransmitter that is negative for sex—in that it can decrease libido or ability to experience orgasm.

If you can decrease the dose of Effexor without an increase in other symptoms, that may help. Decreasing the dosage may mean other symptoms comes back, or that orgasm is still out of reach or diminished. In those cases, I offer Viagra, used off-label for women. A number of clinical trials have shown Viagra to be helpful when SSRIs (selective serotonin reuptake inhibitors, a class of treatments for depression and other disorders) lead to an inability to experience orgasm.

A newer SSRI, Pristiq, is reported to have fewer negative sexual side effects. I’ve seen that to be true, but also have worked with patients who found that health insurance was not supportive, since newer drugs are often more expensive. It may be worth exploring!

Another alternative that works for some women is to take a ‘drug holiday': skip the daily dosage of the SSRI on a weekend day when they are more likely to be sexual. This doesn’t work for everyone. Some people have withdrawal symptoms or other unintended side effects with the ‘holiday approach.’

I encourage women in my practice to consider using a vibrator, which can increase sensation and sometimes lead to orgasm. At midlife, it’s important to stay sexually active (that ‘use it or lose it’ thing), so it’s worth the effort to experiment.

I see how frustrating this dilemma is for women to manage through! I wish you patience and perseverance to find the right balance of overall health and intimacy for you.

Q: Which of my medications is inhibiting my orgasm?

You say you're taking daily doses of Wellbutrin and Effexor. Effexor is the likely culprit, since Wellbutrin is actually "pro-sexual."  Wellbutrin increases dopamine, a neurotransmitter beneficial for sex; Effexor increases serotonin, a neurotransmitter that is negative for sex—in that it can decrease libido or ability to experience orgasm.

If you can decrease the dose of Effexor without an increase in other symptoms, that may help. Decreasing the dosage may mean other symptoms comes back, or that orgasm is still out of reach or diminished. In those cases, I offer Viagra, used off-label for women. A number of clinical trials have shown Viagra to be helpful when SSRIs (selective serotonin reuptake inhibitors, a class of treatments for depression and other disorders) lead to an inability to experience orgasm.

A newer SSRI, Pristiq, is reported to have fewer negative sexual side effects. I've seen that to be true, but also have worked with patients who found that health insurance was not supportive, since newer drugs are often more expensive. It may be worth exploring!

Another alternative that works for some women is to take a 'drug holiday': skip the daily dosage of the SSRI on a weekend day when they are more likely to be sexual. This doesn't work for everyone. Some people have withdrawal symptoms or other unintended side effects with the 'holiday approach.'

I encourage women in my practice to consider using a vibrator, which can increase sensation and sometimes lead to orgasm. At midlife, it's important to stay sexually active (that 'use it or lose it' thing), so it's worth the effort to experiment.

I see how frustrating this dilemma is for women to manage through! I wish you patience and perseverance to find the right balance of overall health and intimacy for you.

Sex and the Sharper Mind

A recent Wall Street Journal headline read, “Sex in Old Age May Lead to a Sharper Mind.” The article describes a study in which Dutch researchers looked into the way cognitive function and attitudes toward sexuality might be related among older people. Nearly 2,000 adults, with an average age of 71, were given a variety of cognitive tests. They were also asked a series of questions about sex—whether it was important for older people generally or themselves personally, whether they found it pleasant or unpleasant. They were asked whether they still benefited from intimacy and touching.

Quite a few—41 percent—said that their current sexuality wasn’t important, but 42 percent said it was important for older people in general. A quarter considered sex important or very important. Only 6 percent found sexual activity unpleasant. More than two-thirds believed that intimacy and touching were still vital.

The results of these questions and the cognitive tests were correlated. Both men and women who thought sex was important and were satisfied with their current sex lives tended to do better on the cognitive tests.

The Wall Street Journal article points out that the study made no claim that sex improves brain function, or vice versa: only that the two are associated. It can be difficult to disentangle cause and effect.

Another study looked at how cognitive function affects sexual behavior interest and sexual behavior among the elderly. The 352 Italians studied were between 65 and 105 years old. They were asked, “Are you interested in sex?” and “Do you have sexual relations?” They were also given two tests of cognitive functioning. One third were still having sex and 40 percent were still interested. This study suggested that a sharper mind might help keep a sex life going.

It could be that older people who are healthy enough to have sex are also healthy enough to do well on cognitive tests. Generally, whatever is good for the brain is also good for sex. That’s a good reason to keep on exercising, or to start.

How Long Should You Wait?

A heart attack, whether it’s your partner’s or your own, is a devastating challenge for any couple. Recovery may be slow. Anxiety and fear are inescapable. Depression is common. The partner who is suddenly thrust into the role of caregiver may, at times, feel overwhelmed. Amid so many physical and emotional challenges, sex may feel like a low priority.

But it shouldn’t. What both of you need most of all is comforting, and nothing comforts like the touch of the one you love.

Both partners may be afraid of risking a recurrence. Not knowing what to do, they wait. Sadly, most are not getting appropriate advice from their doctors. In a recent study of patients aged 55 or younger, only 12 percent of the women and 19 percent of the men talked to their doctors about sex, and patients were more likely than doctors to bring it up (and I'd wager the numbers grow smaller with older patients). As one man said, “The subject was never mentioned in ten weeks of after-care sessions for life style and food advice and recuperative gym exercises.”

When sex did get talked about, two-thirds of the doctors gave advice that was more restrictive than the American Heart Association guidelines. Jalees Rehman writes, “The kind of restrictions recommended by doctors in the study—and presumably by medical practitioners who weren’t polled—are not backed up by science and place an unnecessary burden on a patient’s personal life.”

Blanket restrictions are unreasonable because every patient and every heart attack is different. It’s vital to discuss with your doctor your case in particular. After an uncomplicated heart attack, one week may be long enough to wait. Or you may need longer. The important thing is to be guided by where you are in your recovery.

Having sex is like doing mild to moderate exercise. If your doctor gives you the okay—and ask if he or she doesn’t give you the answers you need!—and if you can handle such activities as climbing stairs and carrying groceries without chest pain or feeling out of breath, sex should be fine as well.

You will be adjusting to new medications. Antidepressants may lower libido, and beta-blockers may interfere with erections. If you’re in open communication with your doctor about sexual issues, dosages may be adjusted or medications switched.

Various stressors are unavoidable, but sex can relieve stress and soothe both patients and their partners. The years of cultivating awareness of your own and your partner’s body will pay off. Care in tending to your relationship in the years before a crisis is like money in the bank. You never know when you might need it.

Sex is exercise, and exercise strengthens heart muscle. Sex also strengthens relationships. It’s a medicine no couple should be without for long.

Q: How does saliva stack up?

You ask whether there's a downside to using saliva as a lubricant. What makes it good for digestion makes it not so good as a lubricant: The enzymes that help break down food can be irritating to the delicate vulvar skin. As we lose estrogen, the vulvar tissue gets more fragile and delicate; what once was fine may become uncomfortable.

I also hear from many women that water-based lubricants don't last as long as they'd like them to; they prefer a silicone or water/silicone hybrid lubricant for staying power through more foreplay.

That said, if it works for you and your partner, you can keep using saliva for some or all lubrication. Just be aware of the potential for irritation, and wash with a warm cloth after sex to minimize exposure.

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