Q: Why am I 'hitting a wall' with sex?

What you describe--feeling like your partner is "hitting a wall" when you attempt intercourse, sounds most consistent with vaginismus. A physical exam can look normal; with careful palpation of the pelvic floor muscles, you can feel them tightening, which is what makes the "wall."

You might go back to your physician with the specific question, "Do my pelvic floor muscles seem too tight?" If that is the case, dilators and/or physical therapy are good solutions. A dilator set will include much smaller sizes--as small as a half-inch--so you can increase your comfort gradually.

Good luck! This is an issue you and your partner can work through.

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!

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?

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!

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.

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.

Q: How, beyond the Vagifem my doctor prescribed, do I work back to sexual activity?

Vagifem will have some influence on tissues within four to six weeks; I hope it won't be long before you note some benefit.

Beyond tissue health and lubrication, having comfortable sex depends on vaginal "capacity." I've recommended vaginal dilators to a number of women who've found them helpful; dilators are smooth cylinders of graduated sizes used to gradually, gently stretch the vaginal opening and depth.

If it really is just dryness (did I say "just dryness"?) making intercourse painful, the Vagifem and a good lubricant should get you back on track. And, of course, remembering to take the time you need for arousal!

Q: How do I apply a vaginal moisturizer?

Vaginal moisturizers can typically be applied in two ways: either with your fingertip in the vagina and externally as needed, or with an applicator in the vagina. Applicators often come pre-filled (like the Yes product offered at MiddlesexMD) for one use, but, in general, the amount to use is an individual decision based on the degree of dryness or discomfort.

Manufacturers of vaginal moisturizers generally recommend application every 3 or 4 days, but, again, it's you who will need to find the frequency that works best for you.

Women I talk to often like the pre-filled applicators for "maintenance" application, and then to use a bulk bottle when they need lubricant for sexual intimacy. And, of course, you might find that a personal lubricant in addition to regular moisturizing is what you like best.

Q: Should I have secretions when I orgasm?

Most of a woman’s genital lubrication comes during arousal, not with orgasm (unless you're wondering about female ejaculation; there isn't agreement about whether this occurs for women, and if it does occur, most women aren't aware of it). And remember, most women can only achieve orgasm with direct clitoral stimulation; few women experience orgasm with penetration alone.

The amount of secretion--or vaginal lubrication--is most dependent on the time and energy and technique put into foreplay or arousal. After menopause, both arousal and lubrication are affected by the absence of estrogen in the genital tissues, which also decreases blood circulation.

Using a vaginal estrogen product (by prescription only) can allow a woman to produce more secretions on her own, which many women prefer. Talk to your health care provider about considering that as an option.

Non-hormonal (and non-prescription) options include vaginal moisturizers and lubricants. Moisturizers (like Replens or Yes) are used every few days and keep the vagina moist and supple; lubes are used at the time of sex to add comfort. The hybrid (Liquid Silk and Sliquid Silk) and silicone (Pink and Oceanus) lubes last somewhat longer than the water-based; water-based lubes may require re-application during a sexual encounter (which can itself be intimate).

Sharing with your partner what feels best to you will be helpful. Let your partner know that a lube is beneficial for your pleasure and find a way, together, to incorporate it in a tasteful, non-embarrassing--even arousing!--way.

Q: Can I have comfortable intercourse after a vaginectomy?

A vaginectomy--surgical removal of part or all of the vagina--is most often done as part of cancer treatment. It's rarely a doctor's first choice, and some reconstruction is usually involved. Your health care provider's evaluation is an important first step.

If your health care provider believes there's physical capacity for intercourse without further reconstruction, there's more you can do to be sure that you're comfortable. A regular routine with a vaginal moisturizer will help keep your vaginal tissues healthy and elastic. You may want to use a lubricant with penetration. Make sure that you're giving yourself time (and attention!) to become fully aroused. Especially if you're having sex again after some time alone, you may be in a rush!

If you're still not comfortable, vaginal dilators may help. They can increase both the vaginal opening and the depth by gradually and gently stretching the tissue.

Keep working at it! Regaining your sex life is definitely worth some time and experimenting.