Q: Would vaginal dilators help me with painful penetration?

Vaginal dilators really do work to increase vaginal caliber--the size of the opening. If you're having your first sexual encounters, have an exam by your healthcare provider to rule out other causes: there may be an issue with the hymen, for example, that would have a different solution.

But for women who've been sexually active, dilators can make a world of difference. I had an e-mail a couple of weeks ago from a woman who hadn't been able to have intercourse for two years. After using vaginal dilators for a month, she was able to have pain-free sex!

Dilators come in graduated sizes; the smallest is only a half-inch in diameter. They are used with a lubricant daily. When you're comfortable with one size, you progress to the next-larger dilator until you've achieved the caliber--the opening size--that works for you and your partner.

Vaginal caliber is only one element of our sexuality, of course. I encourage women to think about the whole picture. But if a narrowing vagina is a problem for you, vaginal dilators really can help.

Q: What can make penetration less painful?

Oooh! "Less painful" is a difficult goal; I'd like penetration to be pleasurable for you!

I'd like you to start with a thorough exam by a gynecologist or someone who specializes in women's health. If the problem is vaginal/vulvar atrophy, then localized estrogen may help to restore some moisture and elasticity. What you describe could also be caused by vulvodynia, which can cause burning sensations and pain with penetration. Again, a healthcare provider experienced in treating mid-life women can help you evaluate options.

If atrophy is profound and longstanding, you may find vaginal dilators helpful, too, in regaining caliber--the size of the vaginal opening.

I do hope you'll investigate--and raise your expectations. The minimum you deserve is no pain; I know you can have enjoyable sex again!

Q: How can I increase sensation and more readily orgasm?

There is no doubt that the ability to achieve an orgasm becomes more difficult as we age, and the orgasm itself is often briefer and less intense. As we age, we need more time for every step of the process, starting with foreplay. Sometimes our partners need to hear a clear message about what's changing for us! We hope our website can make it easier to have those discussions with a partner.

Using a warming lube, like Oceanus G Stimulating or Sliquid Organics Stimulating O Gel, can improve sensation for some women. Warming lubes include a minty or peppery ingredient, which increases circulation and sensation in genital tissues.

You mention occasional orgasm success with a vibrator. Not all vibrators are alike: Some don't provide the intensity of vibration that our tissues need in midlife. We offer vibrators by Emotional Bliss that are more powerful than average, designed for those who specifically need more stimulation, more intensity. I’ve seen some amazing results with these in women who previously were unable to have an orgasm because of neurologic diseases or medications that are known to interfere with orgasm.

You might also talk to your health care provider to see whether vaginal (or localized) estrogen is a good option for you. Lack of estrogen to vaginal tissues results in a decrease in circulation, which leads to less sensation, which is why you may not sense penetration as you did before.

Do talk to your partner and explore your options. Sexual satisfaction comes in many forms, but if you're missing orgasms, there's no reason to leave them behind.

You Never Know: Staying Ready for Sex

I had a call the other day from a friend who’s been a widow for several years. “I’ve found someone!” she told me, with just the slightest quiver in her voice. “I’m so excited I can hardly concentrate at work.”

Of course I was happy for her -- and happy that she called to set up an appointment with me for an exam in anticipation of resuming her sexual life. “I think everything’s going to be okay,” she said, “but I think I might want to come in and see you first so you can tell me for sure.”

She did come in to see me and I was glad to be able to reassure her that, from a physical perspective, she was good to go. If I am able to place two fingertips in a patient’s vagina without causing pain or discomfort, it’s a good bet that she’s going to be able to have intercourse comfortably.

But more than a few post-menopausal patients who come to my office have been astonished to discover that they can’t pass the two-finger test. Their vaginal walls have narrowed and thinned over a period of time without regular intercourse, and I have to tell them it’s going to take some work to get back into a condition where penetration will even be possible, let alone comfortable.

I run into this fairly frequently with women who are widowed and divorced at our stage of life. They are grieving or angry -- or both -- and, without thinking too much about it, decide that their sexual days are behind them. Don’t need to worry about that anymore! But, as my ecstatic friend can attest: You never know. Surprises happen, and when they do, it sure would nice to know that your body’s ready and able to experience the pleasures of intercourse.

It’s one of my biggest concerns for single women our age. If you’re 30 when you divorce and 40 when you want to take it up again, there’s been no lost ground. But if you’re 50 and decide to resume sex at 60, it’s a very different story. You find yourself in a new relationship, you’re ready to be intimate, but your vaginal “architecture” has changed. It can be a very unhappy surprise.

Physical therapy with vaginal dilators can help to restore capacity for intercourse, but it’s much simpler -- and more pleasant! -- if you don’t lose that capacity in the first place. For all my patients and friends who are currently without partners, I recommend a “vaginal maintenance plan” that will help them keep their genitals healthy and ready for love: moisturize regularly; use a good lubricant; and experiment with a personal vibrator or dilator to preserve your capacity for penetration.

Because you never know.

Q: Can I get an over-the-counter estrogen cream for vaginal dryness?

Estrogen-containing vaginal preparations are prescription only. If you haven't tried lubricants and moisturizers, which are available over the counter, you might try those first.

Lubricants are designed for short-term effect, to make intercourse immediately more comfortable. They can be water-based, silicon-based, or a hybrid of the two.

Vaginal moisturizers are designed for longer-term maintenance of your vaginal tissues. They don't contain hormones, so don't require a prescription. They're typically used every several days.

Localized estrogen, which is available as a ring or vaginal tablet in addition to cream, helps to increase blood flow and elasticity in genital tissues. If you've tried lubricants and moisturizers and haven't yet been comfortable during sex, consider talking to your health care provider to see if localized estrogen or another hormone therapy might be right for you.

Q: I quit the pill and tested mid-menopause in one month; now sex hurts. Suggestions?

Isn’t it amazing how quickly things can change? You say you were tested as being mid-menopause. Blood work is accurate at assessing ovarian function on the day you're tested, but it is miserable in predicting what may happen in the next weeks or months. An FSH level may come back 40 (suggesting menopause) on one day, but you may ovulate 6 weeks from now at have an FSH at 8. It's really only over time that you really can better understand if this is the ‘new norm’ or transient. Perimenopause is known to have fluctuating symptoms; once in menopause, most women's symptoms are more predictable.

To make sex comfortable again, I would start with a lubricant. I would try a water-based lube like Carrageenan or Yes. If using a lube makes you comfortable and doesn't irritate the area, that can be a great, simple solution for now.

A warming lube can add some additional sensation for arousal and make orgasm somewhat stronger. Try Oceanus G Stimulating or Sliquid Sensations. Occasionally the warming lubes can be irritating if the area is sensitive, which is why I'd start with a non-stimulating water-based lube; then test a small amount of the warming lube to see if it works for you!

Good luck! I know you can have satisfying sex again.

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: What do I do about pain during intercourse?

If you have pain during intercourse, you need a good, thorough physical exam to start, to make sure there is no obvious cause for the pain with penetration (for example, vulvodynia/vestibulodynia). If the exam doesn't identify any apparent physical cause, you might spend some time on MiddlesexMD's recipe for sexual health, walking through each component to see what makes a difference:
  • Understand the physiology of menopause so you understand what you're compensating for.
  • Learn to care for your vulvo-vaginal tissues, including considering moisturizers or lubricants.
  • Compensate for less sensitivity in genital tissues with more stimulation -- and more patience!
  • Maintain pelvic floor muscles to encourage circulation and maintain orgasms.
  • Attend to emotional intimacy -- because the brain is a vital part of arousal for women.
Our website is structured to help you learn about and address each of these topics; just follow the tabs across the top. You'll need patience to figure out what combination of strategies will work for you, but continued use of the vagina is recommended for continued sexual activity. Avoidance because of pain only makes matters worse. Be in touch if you have questions as you explore possible approaches to get past this pain. It's worth the time you spend!

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!