Q: Can I have sex again? It’s been a few decades...

Sounds like you’ve been doing a number of the right things: You’ve been using dilators, a vibrator, lubricant, and vaginal moisturizer. It sounds like you’re at a point where localized estrogen, Osphena,  or Intrarosa would be helpful for you to achieve your desired outcome.

You asked. Dr. Barb answered.Any of these prescription drugs will provide elasticity, a critical factor for getting the “stretch” needed with the dilators. Take your dilators in to your health care provider and have this conversation, too. He or she can help you determine whether you can get further capacity with the methods you’re using or whether, as I suspect, you need to take the next step and add a prescription to your routine to restore health to the vaginal tissues.

It’s hard to get to the final goal without that option--and that final goal is definitely one worth working for! Good luck.

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.

 

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: Can I use an organic olive oil-based cream with dilators?

While the cream you describe would be fine with the dilators themselves, we doctors recommend against using oils in the vagina. Oils tend to promote the growth of bacteria and break down or weaken tissues. Lubricants especially made for vaginal use are worth the investment.

If you're using silicone dilators, use water-based lubricants with them. Silicone lubricants on silicone products (dilators or vibrators) will cause the surface to degrade over time.

Q: What is my "vaginal cuff"?

As you suspected, the "vaginal cuff" is the healed incision at the top of the vagina after the surgical removal of the cervix and other pelvic organs.

The vagina is just as functional as it was before surgery, but the depth is unpredictable. The tissue is somewhat elastic and stretchy–comparable to the inside of your cheek when you poke your tongue against it. If there seems to be less depth than you (and your partner) need, using dilators can gently and gradually stretch the tissue to a new capacity.

An intravaginal vibrator (like the Liv2) may be helpful to you as you determine what your needs and your new reality are. Sincere congratulations on achieving remission from the cancer for which you were treated, and best wishes as you rediscover your sexual self!

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: Why am I too tight for sex?

What you describe could well be vaginismus, which is the involuntary spasm of pelvic floor muscles of the outer (lower) third of the vagina. The resulting interference with intercourse is experienced as "too tight," "he can’t get in," or "it’s like he's hitting a wall."

Because the spasm is involuntary, the cause is sometimes difficult to understand. Pain in the area of the pelvis can be a contributing factor, so the hip pain you describe is likely involved. Beyond interfering with intercourse, vaginismus--those pelvic floor muscles in spasm--can also be experienced as pain in the pelvis, low back, low abdomen, and upper thighs.

It's important to have an exam to better understand what's happening for you, and I'd advise that you have the exam sooner than later. If you have surgery in your future, physical therapy that starts before-hand (and continues after) could help in your recovery, too. Vaginal dilators are often a part of therapy for vaginismus, and that, too, can start now and deliver benefits for your recovery.

Good luck in working through this! With patience and good information, you can do it.

Q: Is my progress with dilators normal?

It sounds like you've done a great job with regular, sustained use of dilators to restore the vaginal opening. Be aware that the top of the vagina tapers a bit, so it's possible that the largest-diameter dilator, because of its width, just won't go in as far as the others. The only way to assess for certain what's happening is to have a pelvic exam with your health care provider; I'd explain to her or him that you've been using dilators and see whether s/he finds anything other than normal.

During intimacy with a partner, many women find that they can control the depth and angle of penetration more easily when they are on top. That seems to be a safer starting point for women who have reason to better understand what's most comfortable–and pleasurable.

Congratulations on taking care of yourself!

To ask your own question, use the "Let's Talk" button top and right on our website. You'll receive a confidential reply via email, and your question may be used as the basis for a Q&A post here on our blog. 

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.

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.