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.

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.

Fifteen Facts about Your Vagina

Out of sight; out of mind. That’s how it is with the vagina. As long as it’s working and isn’t causing a fuss (which, granted, becomes more iffy at this stage of the game), we forget about it.

Nothing wrong with that.

But, ladies, your vagina is a marvelous thing, so in the interest of a little community ed on this underappreciated organ, here are some fun and quirky facts—maybe things you didn't know—about your vagina.

  1. The word vagina comes from the Latin word for “sheath” or “scabbard.” Those Latin lovers were all about their swords. The word orgasm originated with the Sanskrit word for “strength.”
  2. The hymen is named after, um, Hymen, the Greek goddess of marriage. It’s a membrane that partially covers the vaginal opening before puberty to protect it until normal changes during puberty. It’s broken with a girl’s first sexual penetration, and the attendant show of blood is the traditional “proof” of her virginity.
  3. As you might imagine, the vagina has accumulated many colorful names over the centuries. A few of the, ahem, more decorous are: camel toe, honeypot, cock pocket, vajayjay, meat wallet, muff, bearded clam, fish taco, crotch mackerel, hot pocket, bikini biscuit, panty hamster, yum yum, twat, hoo ha, and, of course, pussy and cunt. Enough already!
  4. The vagina proper begins at the mouth of the vulva and ends at the cervix, which is that bottlestopper at the base of the uterus. So the vagina is the conduit—the “potential space,” the empty sock without a foot in it—that leads from outside the body to the small opening in the cervix that allows sperm to pass through.
  5. While the vagina is only 3-4 inches long, it balloons to 200 percent its normal size (to accommodate those Latin swords as well as babies of various sizes). This impressive ballooning effect happens because the vagina is pleated like a skirt with a bunch of folds, called rugae, which expand when extra space is needed.
  6. We talked about the normal variations in the way your outer genitalia may look, but for the most part, vaginas all look the same.
  7. Like your oven, your vagina is self-cleaning. So, for heaven’s sake, don’t douche. You’ll upset the delicate balance of good bacteria that live in there. Wash your external genitals with warm water and some gentle, unscented soap.
  8. Your vagina has its own unique odor, which is determined by your diet, the normal variation in bacteria, sweat, and hygiene.
  9. Your pubic hair isn’t just an annoying decoration. In days of yore, it was a “reproductive billboard” announcing that over yonder was a fertile female. It also traps your scent, leading suitors to the honey pot. Times have changed since caveman days, and a healthy mat of hair may not be quite so irresistible today. Pubic hair has a life expectancy of only three weeks versus head hair, which stays put for about seven years.
  10. The normal pH balance in your vagina is slightly acidic, similar to wine or tomatoes. That normal balance can get out of whack if you have an infection, douche, or through exposure to semen, which is more alkaline.
  11. Sex keeps your vagina moist and flexible, especially after estrogen levels drop. “Safe vaginal intercourse can help keep the vagina healthy and dilated,” says Dr. Courtney Leigh Barnes, a gynecologist at the University of Missouri in this article.
  12. Vaginal farts (also called queefs or varts) happen to every female at one time or another, especially during sex or exercise. So don’t be embarrassed.
  13. Gravity is as hard on your vagina as it is on your breasts, face, and buttocks. It sags, and sometimes, it falls out. This is called a prolapse. While it may be uncomfortable, it’s usually painless and can be fixed.
  14. Most women (about 70 percent) don’t orgasm through vaginal stimulation alone, but through a combination of clitoral and G-spot action.
  15. The first two inches in the vagina have the most nerve endings and are the most sensitive.
Don't say we never told you.

Estrogen Where It’s Needed

Okay, so you’ve tried everything. You regularly use a good, natural moisturizer, plus a lubricant during sex. No soaps, sprays, scents, dyes, or synthetic underwear ever touch your bottom. You’re the queen of vaginal hygiene. And still you’re troubled by dry, itching, or inflamed genitals and painful penetration.

What now?

Talk to your doctor about using a localized estrogen product for your vagina. These medicines deliver low dosages of estrogen right where it’s needed: the vagina and vulva. Not only is localized estrogen medication very effective at relieving the discomfort of vaginal inflammation or atrophy, but it also restores natural vaginal lubrication and elasticity. In fact, while it won’t relieve other menopausal symptoms—like hot flashes—low-dosage vaginal estrogen is sometimes more effective in relieving menopausal genital problems than systemic hormone replacement therapies (HRT). Moreover, the dosages are so low, the side effects and complications so negligible, it is often used by breast cancer survivors.

Vaginal estrogen comes in several forms: a cream (used twice a week), or slow-release tablets (used twice a week), or a ring (which needs to be replaced every three months). Don’t, however, confuse the Estring vaginal ring with Femring, which is the high-dosage HRT in a vaginal ring form. (Confusing? It can be.) Your doctor will tailor the amount and frequency of application for the maximum effect at the lowest possible dose. It may also take several weeks for treatment to become fully effective.

A few precautions:

  • Avoid applying your estrogen cream right before intercourse, since your partner can absorb it through his penis. Estrogen rings and tablets are meant to stay in place and don’t have this effect.
  • Continue to use non-hormonal lubricants and moisturizers if necessary.
  • Have regular vaginal intercourse to augment natural lubrication and a healthy vagina.
While localized estrogen may not be the first line of defense against the unpleasant genital changes related to menopause, it’s an important option when simpler methods (like vaginal lubricants or moisturizers) fail.

Taking Care of Yourself. Intimately.

As a medical doctor, I try to provide a place where uncomfortable or unfamiliar topics can be discussed in an open, honest way, without inhibitions or worries about “what people might think.” For lots of people, both men and women, self-stimulation or masturbation falls into that “uncomfortable” category. Some of the myths surrounding masturbation—like it causing blindness or hair to grow on the practitioner’s hands—have faded, thank heavens! But there’s still a lingering perception, I find, that self-stimulation is somehow less acceptable for women than for men. MiddlesexMD_OnlyBody

For post-menopausal women, self-stimulation is especially helpful, whether or not they have partners. It can solve problems with vaginal dryness or tightness: Stimulation causes your clitoris to swell, helping to maintain healthy blood flow to the walls of the vagina, which in turn can help keep your vagina open, strong and responsive. (It’s the old “use or it lose it” rule.)

If vaginal dryness or tightness is a problem, self-stimulation can also be a way to temporarily feel sexually satiated if intercourse is too painful. I say “temporarily” because I don’t recommend that you think of it as the solution to painful intercourse. Always seek medical attention if you’re experiencing any kind of vaginal pain, because there are lots of remedies.

Another benefit of stimulating yourself is the way it helps you to get to know your own body and what satisfies you best. As hormone levels decrease and effect other changes in your body, what’s worked in the past may not be as satisfying now. It’s great to be able to experiment with your partner to find your new best experience, but that’s not always possible, for all kinds of complicated reasons. Old habits die hard, and either you or your partner may feel tense or intimidated about changing things up. You can experiment to see what works for you and then share that knowledge with your partner to make your sex lives more mutually satisfying.

If you don’t currently have a sex partner, self-stimulation is a great way to enjoy the side benefits of sex, like tension and stress release and the feeling of calm and relaxation that immediately follows a sexual session. Fantasy can be a fun part of it; picture yourself with a former lover—or George Clooney (or Dean Martin… or… you tell us!). And taking care of yourself in this way keeps open the possibilities in case you do find yourself in a relationship again. In my decades of practice, I’ve learned never to say never!

If your sex life is suffering from other issues—a rough time in your relationship or it seems to hard to get your love life back on the right track—I caution patients against replacing intimacy with a partner with self-stimulation. It may be the “easy” thing to do, but it can compound problems if you turn to self-stimulation instead of your partner for satisfaction.

Self-stimulation is a normal part of a healthy sex life. At this point in our lives, the last person we need to be shy with is ourselves. Who knows what we’ll learn?

Moist is Good

In the last post, we talked about how pH levels affect the vagina. The second part of good vaginal health has to do with moisture. As we say at MiddlesexMD, moist tissues are strong tissues.

Normally, your vagina moisturizes and cleanses itself by secreting a clear fluid that seeps from blood vessels in the vaginal wall. When you become sexually aroused, blood flow increases, and so does the lubrication. Unfortunately, this process is regulated by estrogen, and we all know what’s been happening to that hormone lately.

With decreasing estrogen levels and circulation, vaginal tissue becomes thin and dry. Maybe you’ve noticed that you don’t lubricate as easily during sex so that penetration is difficult or painful, or maybe you’ve experienced vaginal dryness and discomfort at other times as well.

The good news is that this condition is easy to fix. You moisturize your skin regularly; you should do the same with the vagina. First, a little refresher on the difference between vaginal moisturizers and lubricants. Lubricants may be used in the vagina and on the penis or toys during intercourse to help with penetration and to make sex more pleasurable. Lubricants come in water- or silicone-based varieties or a hybrid of the two, and in various viscosities (thick to thin). Choice of lubricant is a highly personal preference and may depend on the activity you have in mind. Because it’s helpful to try different kinds, we’ve compiled a sampler kit of our favorites.

Lubricants last several hours, and the only rule of thumb related to vaginal health is that no oil-based product, including petroleum jelly, should be used in the vagina. They’re hard for the vagina to flush out; they tend to disrupt pH balance; and they also tend to deteriorate condoms. Lubricants can be used in addition to a moisturizer.

The sole purpose of vaginal moisturizers, on the other hand, is to keep vaginal tissue moist and healthy. Moisturizers last two or three days and should be used regularly, just like facial products. And just like anything you use on your body, you want your vaginal moisturizer to contain natural, high-quality ingredients. A few common ingredients in vaginal moisturizers (that are also present in lubricants) bear some examination:

  • Glycerin. Widely used in moisturizers and lubricants, glycerin is a colorless, sweet-tasting substance that can exacerbate a yeast infection by giving the organisms sugars to feed on. If you’re susceptible to yeast infections, find a glycerin-free moisturizer.
  • Parabens. In all their hyphenated mutations (methyl-, ethyl-, butyl, and propyl-) parabens are a widely used preservative and anti-microbial agent. While some contamination-fighting ingredient is a good idea in these personal products, a few recent studies have found very slight health issues that may be linked to parabens. A bigger problem is the potential for an allergic reaction that could be related to parabens or other ingredients in moisturizers.
  • Propylene glycol. Used as a fragrance and to control viscosity, propylene glycol has also been linked to skin irritations and allergies.
While none of these substances present major health risks, it’s a good idea to make an informed decision about your personal care products. Read the ingredient list in your moisturizer; the fewer unpronounceable names, the better. If you can find a product that uses natural ingredients and that works for you, wouldn’t that be your first choice?

Vaginal Health Begins with Bugs

When you think about it, the vagina is a pretty undemanding organ. It’s cooperated through childbirth and nights of passion; it’s soldiered on uncomplainingly throughout years of menses and the occasional “oops”—such as the patient of mine who applied Retin-A skin cream instead of Vagisil, or the friend who used Ben-Gay. Her vagina did a little complaining then, but soon returned to its cheerful self.

Because the vagina has rarely been the squeaky wheel, we’ve tended to tend to take it for granted. As we age, however, vaginal tissue thins, loses elasticity, and becomes dry, so, like other parts of our bodies, that wheel tends to squeak a little louder.

Often, vaginal troubles can be addressed—or avoided altogether—with some TLC. While few of us think about how to maintain optimal vaginal health, maybe it’s time to give that longsuffering organ some extra attention. The two major factors in maintaining a healthy, uncomplaining vagina are a good bacterial balance and moisture.

First, a science lesson: pH is a measure of how acidic or alkaline (basic) a substance is. The pH scale ranges from 0 (very acidic) to 14 (highly alkaline) with seven being neutral. A healthy vagina is slightly acidic, in the range of 4.5 to 5. This acidity is maintained by a delicate balance of organisms, notably the bacteria lactobacillus that produces lactic acid. This slightly acid environment helps to ward off infection.

When the pH level in our vagina is out of whack, unwanted bacteria and other organisms can flourish—Candida albicans, for example, which is the fungus causing yeast infections. Sometimes it doesn’t take much to upset the balance. A surgary diet, some kinds of soap, a round of antibiotics, or even one of those nights of passion can upset the flora in the vagina. Sperm, for example, is alkaline with a pH of 7 to 8, and so is blood with a pH of 7.4, which is why hygiene is especially important if you’re still menstruating.

Here are some suggestions for maintaining a good pH balance and for overall vaginal hygiene.

  • Don’t douche. Douching actually increases the risk of bacterial infection and reduces the “good” lactobacilli in the vagina. The vaginal walls produce a clear fluid to flush out foreign substances (more on this in the next post), so douching is both unnecessary and harmful.
  • Maintain good air flow. Wear cotton panties and loose clothing—at least some of the time! Avoid relying on silks and synthetics that trap moisture on the vulva. Don’t wear thongs. Change out of wet bathing suits or clothing promptly.
  • Avoid scented products: feminine sprays, soaps, bubble bath, scented pads or tampons. They can be irritating, allergenic, or alkaline.
  • Wash your bottom with warm water. Soap is drying to the delicate vulva and inner labia, and some soaps are alkaline.
  • Use tampons rather than pads and change them regularly.
  • Keep bacteria where they belong. Wipe from front to rear.
  • Avoid sugars and refined carbohydrates. They can create an environment that feeds fungi.
  • Talk to your doctor about maintaining good vaginal health if you’re prescribed antibiotics. He or she may suggest eating yogurt, for example, or taking Lactobacillus acidophilus tablets.
  • Wash underwear with mild soap, such as Woolite. Rinse well. Avoid scented fabric softeners.
At the end of the day, all our parts are interconnected, so it’s not possible to maintain good vaginal health if the rest of your body is unhealthy. Smoking, obesity, and diabetes are all conditions that compromise health, including vaginal health. Good general habits, such as a healthy diet and exercise to maintain good muscle tone, are probably the most critical elements to a healthy vagina. But you knew that.