Q: What size dilator should be my goal?

I wish there were an exact “science of measurement” that would answer your question definitively. The vagina is typically elastic--especially when we’re younger--and will stretch to accommodate any (or nearly any) size required, but there can be male/female matches that are outside of that range.

You asked. Dr. Barb answered.As we get older, our vaginas become less distensible and less elastic. The tissue itself becomes less elastic as we lose estrogen, and we lose the “pleating” we had when we were younger (I’ve used the analogy of going from a pleated skirt to a pencil skirt). Dilators work by gently and gradually stretching the vaginal walls, making them open enough (called patency) to allow for comfortable intercourse.

Because of the variations in tissue elasticity, atrophy, a woman’s anatomy, and her partner’s anatomy, the goals are comfort and pleasure, not a specific dimension. Dilators come in sets of graduated sizes, so a user can move from one to the next-larger as she gains comfort with each. Some women will progress through the entire range of sizes; others will be satisfied before that.

We offer a variety of dilators, because women’s preferences vary. Our most popular, the Amielle kit, includes five sizes and a removable handle that provides more length for maneuvering. For those who prefer a solid dilator, we offer a six-inch-long option in a set of five or a set of seven, again depending on need. And for some women, the texture of silicone and its ability to be warmed makes the Sinclair Institute set of five their preference.

I hope this is helpful! I’ve very happy to hear that you’re still tending to your sexual health.

 

 

Q: What can you tell me about Intrarosa?

You asked. Dr. Barb answered.Intrarosa is a new product for treating vaginal atrophy, approved by the FDA in November of 2016. It will be available by prescription only; it’s not yet in pharmacies but is likely to be later in 2017. The clinical trials for Intrarosa are favorable for treating vaginal atrophy, or genitourinary syndrome of menopause causing painful intercourse. It is an adrenal hormone, prasterone (dehydroepiandrosterone), formulated as a once-a-day vaginal insert.

Q: What’s the story on MonaLisa Touch?

MonaLisa Touch is a laser treatment for vaginal atrophy, also known as genitourinary syndrome of menopause. I explained the treatment option in a blog post a few months ago.

You asked. Dr. Barb answered.The treatment is quite effective for most patients, but it is costly. As a new procedure, it’s not covered by most insurance companies; without insurance coverage the expense (cost varies by region, but figure $1,500 to $2,000 for the three required treatments) is a limitation for many. The procedure needs to be updated regularly, probably about once a year for most women.

We also lack long-term data on its efficacy and side effects. We are very hopeful the clinical trials will soon be available to assure its effectiveness and safety.

 

Simple Tools for More Comfort

The MiddlesexMD team and I spend some time at medical conferences, so I know that vaginal dilators aren’t a mystery just to a lot of women: They’re also a mystery to some medical professionals! Dilators are one of the biggest sources of curiosity when we show our products at those conferences (the other, in case you’re curious, is Kegel tools).

Less estrogen means less elasticity in our tissues. Tissues that were actually pleated—imagine how a pleated skirt can expand and swirl!—become flatter and therefore less stretchy—think pencil skirt. Moisture helps, but so does some regular and gentle stretching, which reminds those tissues of what it is we’d like them to do—both in width and depth.

That’s where vaginal dilators can help. Dilators are typically offered in a set with graduated diameters, starting at about a half-inch and increasing to an inch and a half or so. If you’re looking to recover what we doctors call “patency,” or openness, you’ll start with the smallest dilator that’s comfortable and work your way up. If you’re maintaining patency, you may be using less of the size range.

We have instructions for using vaginal dilators on our website. As with moisturizers, regularity is important—and you know that’s true for many areas of self-care, from exercise to hand lotion.

At MiddlesexMD we offer a variety of dilators, so you can choose the set that works best for you. All of them meet our criteria for safety (safe materials and quality manufacture) and effectiveness (size increments and firmness for insertion). I’m happy recommending any of them, which actually gives me pause in calling out what’s good about each—feels almost like naming a favorite child! The Amielle set, which comes in a pouch, is our lowest-price option, so if cost is a barrier for you, grab that one and go! This set of five, made by a medical-products company, I like for its size range (there’s a set of seven, too) and feel; because they’re solid, they have some heft. And our newest option,are made of silicone, which has some benefits: You can warm them for more comfortable use, plus they just feel more “touchable.” Their colors are cheerful and friendly, too, which doesn’t hurt!

These descriptions suggest some criteria for you to use in making a choice. If you’re working with your doctor or physical therapist to treat a specific condition, she or he may have additional advice about which might work best for you, as well as how you adapt their use for your situation. Don’t be shy about asking!

I had a woman in my practice just the other day who told a typical—but, for her, life-affirming—story: She’s been single and, when she found a new guy to be serious about, she also found herself unable to have intercourse. Now, after three months of dilator use, she’s having sex comfortably. Such a simple tool, you’ll think when you’ve seen or tried them. But, trust me, so effective.

Q: Are my tissues shrinking down there?

What you ask about specifically is your clitoris, which, along with other genital tissues, does typically shrink with the loss of estrogen—whether through menopause or some other medical event. Because you're under 40, which is young for what you're describing, I'd encourage you to express your concern to your health care provider and have a thorough pelvic exam. The exam will be helpful in finding out whether there's another vulvar condition causing the tissue changes—or whether you're experiencing normal changes.

As we lose estrogen, we do face something of a "use it or lose it" proposition. That is, circulation and stimulation keep our genital tissues healthier; left to their own devices, they'll atrophy. If you don't have a partner right now, a vibrator is a great choice to provide stimulation and increased blood supply to the area. Maintaining your health means you'll be ready for intimacy when—just when you least expect it—a relationship emerges!

Q: Can Estring help me regain intimacy?

From what you describe, you've experienced the kind of atrophy that's very common in post-menopausal women. Without intervention, some estimate that women lose up to 80 percent of their genitals—which is surprising to many of us, just as puberty is sometimes surprising! It's good to act just as soon as you can, and then maintain the progress you've made.

From what you describe, I might recommend that you look at creams or tablets for localized hormones to start. The Estring is inserted for 90 days. Having any foreign body placed in fragile tissues causes irritation or ulcerations for some. But once you've achieved a healthy vagina, you could switch from other forms to the Estring, which certainly has a convenience advantage.

Adding estrogen for two to three months will tell you what other actions might be helpful. Along with the vaginal tissues becoming fragile and thin without estrogen, the vagina actually becomes shorter and more narrow. Dilators help to restore capacity, and they're easy to use.

Congratulations on deciding to reclaim intimacy with your husband! Best of luck, and we're here if you have questions along the way.

Why do I feel razor blades during sex?

Ouch! That's a description I hear more often than you think. You're not alone. Other women also describe the sensation as sandpaper, cutting, burning, or ripping.

When a woman describes that sensation, it's usually caused by vaginal atrophy, or more likely vestibulodynia/vulvodynia. A careful exam is needed to determine exactly what's happening; proper treatment can make sex comfortable again.

It's likely that vaginal estrogen is necessary to make those tissues healthier; that alone may solve the issue. If that doesn’t completely resolve the pain, treatment options for vestibulodynia/vulvodynia should be explored.

Yes vaginal moisturizerThe good news is that there is nearly always successful treatment! You can regain the intimacy you're missing in your relationship.

Keeping Things Open

Maybe you’re divorced or widowed. Maybe you’ve been single and partnerless for a while. Maybe you found someone after a long dry spell. Or, maybe sex has just been darned painful lately.

Time was, you could count on your vagina to do its job. It just worked. You didn’t have to think about it. But with loss of estrogen you’ve been experiencing lately, that uncomplaining organ begins to act up. And if you haven’t used it lately, it actually begins to shrink and shorten.

Now, if you’ve been on the sidelines, sexually speaking, for a while, you won’t be able to jump back into the game without some preparation. At this point, sex can be surprising, and not in a good way.

After menopause, the name of the game is “use it or lose it.” Furthermore, it’s a lot easier to maintain vaginal health than to play catch-up after ignoring the situation downtown for a while.

As we explain in detail in our recipe for sexual health, when you lose estrogen, the vaginal walls become thin, dry, and fragile. They atrophy. Without regular stimulation, the vagina can become shorter and smaller. It can also begin to form adhesions and stick together. Some cancer treatments exacerbate this process.

We’ve talked about moisturizers, practicing your kegels, using a vibrator or other form of self-pleasuring as part of your sexual health maintenance program.

But another important tool, especially if you’re currently without a partner (or are trying to rehabilitate now that you’ve found someone) is the regular use of dilators.

Say what?

Dilators are sets of tubes, usually made of high-quality, cleanable plastic, that start small (half-inch) and gradually larger (up to an inch and a half). They’re inserted into the vagina in gradually increasing sizes to stretch the vaginal walls, making them open enough (which is called patency) and capacious enough to do their job.

It isn’t quick, but it is effective.

Occasionally, I run across suggestions for homemade dilators that make use of various round objects. Don’t try this. It’s important for all kinds of reasons to use only high-quality dilators that are smooth and easy to hold, that increase in size gradually and consistently, and that can be cleaned well.

You should only use the safest, highest quality product in this important place. If you don’t know where to look, we offer a selection of dilators on our website that we’ve carefully vetted. These will work much better for you than those candles you were eyeing.

Here’s how you use them:

Relax. Take a bath—it makes all those tissues soft and pliable. Lie comfortably on your back with your knees open.

Lubricate the smallest dilator well with a vaginal lubricant.

Gently insert it into the vagina. Keep all those pelvic floor muscles relaxed. Breathe. Push the dilator in as far as you comfortably can.

Hold it there for 20 to 30 minutes. Do this twice a day.

When you can comfortably insert the smallest dilator, graduate to the next largest size.

It can take three months or more to restore vaginal capacity.  Once you’re comfortable with the largest dilator, continue the regimen at least once a week if you aren’t having sex regularly. And don’t forget the moisturizers.

It takes patience and diligence to rehab your bottom, but you can do it. With a little TLC, everything will work as well as it ever did and sex can be every bit as luscious as it ever was.

Q: How frequently do I use dilators?

So glad you've been successful with the dilators you ordered from MiddlesexMD! Vaginal dilators can help to restore capacity and comfort for intercourse. Our website has instructions for how to use them to restore the vaginal opening.

Once you've been successful with that therapy, if you're not having regular intercourse, I recommend that you use dilators at least once a week to maintain the progress you've made. Stimulation is important to retaining vaginal health—which is what we mean when we say "use it or lose it." If you find that you're having more discomfort, increase the frequency of dilator use.

Post-menopausal women find that using a vaginal moisturizer (like Yes or Emerita) really helps to maintain elasticity.

Congratulations on following through with the dilators—and stay with it! You'll find it easier to maintain than to regain your comfort.

Q: Could fibroids cause tenderness during and after intercourse?

You say you were diagnosed five years ago with fibroids, and you've reached menopause (one year without periods) quite recently. The good news is that fibroids tend to shrink in menopause, so they're unlikely to be causing the soreness you describe after deep intercourse.

The less good news is that your symptoms sound most consistent with vaginal atrophy, the typical consequence of the absence of estrogen in the vagina. I'd recommend that you start using a vaginal moisturizer or vaginal estrogen as soon as possible. The moisturizers are readily available; you'll need a prescription for the estrogen, which comes in a variety of forms for local application.

What you're experiencing is normal and easily treated—more good news!