MiddlesexMD

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.

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.

Q: Can I tighten my vagina?

You can’t really tighten your vagina. What you can do is tighten your pelvic floor muscles, which surround the vagina. We offer a variety of products designed to help you improve pelvic floor tone, as well as instructions on how to do Kegel exercises.

There are some laser treatments that have been offered to tighten the vagina. They’re relatively new treatment options, and the outcomes seem quite variable.

I hope this helps! (And I’ll note that strengthening your pelvic floor is also good for preventing incontinence, so there’s lots of reason to develop the Kegel habit!)

Q: Is it too late for me to restore sexual health?

You say you reached menopause (one year without a period) six years ago. Sex has become painful, and you want to “get it back.”

It’s never too late! Using a vaginal moisturizer may be of some benefit, but if you’ve had pain for several years, you may need a prescription treatment option to restore comfort. There are localized estrogens and Osphena (a non-hormonal option) that are very effective at restoring vaginal health. I have a patient who had not had intercourse in over 25 years. Within 3 months of treatment she was able to resume--and enjoy--intercourse! It is absolutely possible.

I would recommend going to a physician/provider who can do a careful exam and confirm the cause of the pain. Atrophy is the most common reason for painful intercourse after menopause, but there can be other causes as well; identifying the right cause makes all the difference to effective treatment.

With effort and follow-through it is nearly always possible to successfully restore the ability to have intercourse.

Q: While I feel desire, I just can’t get aroused. What’s up?

You describe having been on bioidentical hormones for a number of years, as well as having had a complete hysterectomy. There are a number of variables that contribute to this mystery.

A couple of thoughts: Are you using testosterone with your hormone therapy? The ability to arouse and orgasm, as well as drive, is influenced by testosterone for some women. Not all women get an improvement in sexual function with the use of testosterone. If you aren’t using testosterone, you may want to have a conversation with your provider about adding it. Virtually all women over 50 have low testosterone, and having ovaries removed is a big factor in low testosterone.

Second, are you using compounded hormone therapy (HT)? I see so much variation in the dosing and absorption of compounded HT that I almost always recommend a pharmaceutical bioidentical HT. I just see so much more consistency in symptom relief.

There is also a relatively new supplement, called Stronvivo, that I have had some great successes with women. They’ve used it--and it’s been tested--for improved sex drive, lubrication, and more. A neuropsychiatrist in my community is recommending Stronvivo for improved memory, too!)

I hope some combination of these suggestions solves your mystery!

Q: Can I satisfy my wife in spite of my size?

You’re concerned that your penis is short, and that since it sometimes slips out during intercourse, you may not be satisfying your wife. The good news for you is that most women--about 70 percent--can’t achieve orgasm only with intercourse. That means it’s unlikely that your size is at fault or you’re doing something “wrong.”

Penetration is not required stimulation for most women; instead, what they need is direct clitoral touch and stimulation, whether by hand, tongue, or vibrator. I’d recommend that you ask your wife what she prefers to feel pleasure and experience orgasm.  

She may very well already know! The sooner you talk about it, the sooner you’ll both be more satisfied. If she’s not sure herself, she can do some exploration herself--or you can explore as a couple. And you can participate fully, knowing that your size doesn’t need to be an issue for either of you.

Q: Why do I have too much pain to have sex?

You say you haven’t been able to have sex with my husband for about a year. You’ve seen a couple of health care providers: One prescribed an estrogen cream, which wasn’t effective, and the other saw nothing “physically wrong” and, since you’re not yet menopausal, recommended lubricants.

What you describe--a feeling of “tearing” or “burning” at penetration--sounds to me like the condition of vulvodynia (also know as vestibulodynia, provoked vulvodynia/vestibulodynia). The classic description is “burning and tearing” pain with penetration; other descriptors are razor blades or sandpaper-rubbing with penetration. Often, sex leaves women with this condition sore or uncomfortable. Vestibulodynia is an under-recognized cause of painful intercourse, and you’re not alone in receiving ineffective advice.

You express reservations about going to another doctor to talk about this issue. I know it’s difficult to bring up, and it doesn’t feel worth the effort if you don’t get solutions for intimacy. But you do need a provider who is familiar with vestibulodynia and knows the treatment options--because it is treatable and you can be intimate with your husband again.

I recommend finding a provider in your area through the North American Menopause Society (link to their practitioner locator here) or through the International Society of Women’s Sexual Health (ISSWSH) (link to their provider search here). If you choose to use the ISSWSH directory, note that the listing includes therapists as well, so be sure to select a physician who does clinical care and can provide the proper examination and treatment.

Please do follow through to find someone qualified to provide treatment. You don’t have to leave this part of intimacy with your husband behind.

Q: What’s causing my yeast infections?

You say you’re using a vaginal estrogen cream, and using Kegel weights with an aloe vera gel. You’ve had two yeast infections since you started using both.

If you are fairly new to using estrogen vaginal cream, it may be the cream that is causing the vaginal yeast infections. The estrogen cream lowers your vaginal pH (and a lower pH is a healthier status; here’s a summary of healthy pH levels) over the first 8-12 weeks of use. The transition from the higher pH (atrophic) to the lower pH puts women at risk for yeast infections. This should not persist, and in the end the estrogen cream is likely to be beneficial to you.

Using the kegel balls shouldn’t cause a yeast infection, but if you’re prone to yeast infections, a pH-balanced lubricant like Yes WB may help prevent them. pH matters!

Sex after Menopause: The Golden Years?

Sex after menopause can be challenging. This website and my medical practice is dedicated to addressing those challenges, so topics like dry vaginal tissue, pain with intercourse, loss of libido get a lot of press here at MiddlesexMD.

But for once, let’s turn the picture on its head. Let’s look at postmenopausal sex from the sunny side of the street.

Sure, menopause isn’t for the faint of heart. It’s a hormonal roller-coaster with a chaser of unpleasant side-effects. Sex can become collateral damage during all the turmoil.

But the big picture? The view from the top of the hill? Not so bad at all. In fact, depending on your inner resources and resolve, both sex and life after the big M can look pretty darned sweet. Some women even report experiencing a resurgence of desire, sort of golden age of post-menopausal sex.

Several elements tend to coincide during those post-menopausal years that contribute to a more serene, predictable life and the potential, at least, for a renewal of romantic zest. For example:

• More time; less stress. Retired or not, you’re probably past actively building a career. The kids are independent and maybe out of the house. You aren’t completing financial reports while sitting at basketball practice. You can linger over a pinot grigio and actually listen to the Tchaikovsky Concerto in D Minor without the distracting din of kids fighting.
• No periods; no pregnancies. A lot to celebrate here. The years of birth control (and worry about the Whoops! factor), the discomfort and nuisance of menses—all in the rearview mirror. You can sleep in and take the triple gatehook locks off the bedroom door. Canoodling can last as long as you want.
• Financial freedom. Generally speaking, the hamburger years are over. You can afford steak, a night out, a nice bathrobe, or even a romance-inducing cruise. All of which can make you feel relaxed, sexy, and vital—and more connected to your honey.
• Fewer crazies. As the hormonal ride levels off, you’ll feel more stable, mature, and confident. You know what you want, sexually speaking and otherwise, and you know how to ask for it. You’re coming into your own—no one is the boss of you.
• Synchronicity. With maturity, the sexual needs of men and women tend to converge. Men slow down and value emotional connection. Women become more assertive. It can be a great time for playful exploration on all levels.

Granted, aging comes with challenges, and they can be unpredictable. But growing older and staying sexy is more about your attitude, and the resources you bring to bear than what’s happening below your neck. “So here’s the big reveal,” writes Barbara Grufferman in this article. “After 50, we’re at a sexual crossroads, and need to make a choice: We could go through menopause, shut down that part of ourselves, lock the door and throw away the key. Or we could embrace this new life with a sense of freedom and fun…”

So that’s the thing: it’s a choice. There are no wrong answers (unless they hurt your partner); instead, you have lots of options. Barriers to good sex are very fixable, both for men and women.

Here’s a list of simple things you can do to enjoy these golden sexual years to the full:

• Preheat the oven. You are responsible for your own arousal, so get to know your body and what it likes. Read erotica. Play with toys. Then teach your partner. Don’t wait passively for Prince Charming to ring your chimes.
• Just do it. Sometimes you have to begin in order to get aroused. Start the kissing and cuddling. It’s quite possible that your brain will catch up. “If you’ve been ignoring, neglecting or denying your sexual self for a while, then you must consciously decide that you want sex in order to even let yourself feel desire,” writes Grufferman.  
• Sex leads to more sex. “Women who have regular sexual activity have less sexual dysfunction [and fewer] complaints,” says Dr. Madeline Castillanos, a psychiatrist and sex therapist in New York City. It’s that “just do it, you’ll like it” thing again.
• Take your time. You don’t have to hurry, and you don’t even have to please your lover. Turning you on is a big turn on for him, too. So you can relax and let go of the worn and useless sense of duty about getting him and yourself off expeditiously.
• Engage in outercourse, says Dr. Sheryl Kingsberg, a psychologist with University Hospitals Case Medical Center in Cleveland. Involve all the senses; practice luxurious, languid, voluptuous sex that may or may not actually require penetration. Most of all, have fun doing it.

According to the experts, the most dependable predictor of good sex after menopause is good sex before menopause. And if it wasn’t so great before, time’s a-wasting. You can apply your hard-won life skills and your intimate knowledge of your partner to begin addressing the issues that stand in the way of intimacy and a solid sex life.

Q: What’s with this period after three years of HT?

You say you’ve had a period and some breast tenderness after three years of hormone therapy (HT). I hope you’ll make an appointment with your health care provider: Any bleeding that occurs postmenopausally (after 12 months with no bleeding) is considered “abnormal uterine bleeding” and it really deserves evaluation. This is true whether or not you’re on HT.

The evaluation is usually an endometrial biopsy, a quite simple office procedure. Women on hormone therapy are at very low risk of developing uterine cancer, but we still want to make sure the proper evaluation takes place. Usually the biopsy is completely benign or normal, and we aren’t able to explain why it happened.

When the bleeding is accompanied by other associated symptoms, like breast soreness, it is tempting to attribute it to a “last hurrah” or one last period, but that is unlikely. Any missed doses of the HT or changes in dosing can occasionally contribute to some breakthrough bleeding. The most likely scenario is that the hormone therapy contributed to the symptoms of the breast soreness and the bleeding, but without any changes it’s hard to explain why that might have happened now, three years after menopause.

Again, evaluation usually confirms that all is normal, but it’s worth making the effort to be sure!

Don’t Settle for a Sexless Marriage

Sexual partnerships are as variable as snowflakes. Each couple dances to a unique harmony. For some, sex remains a vibrant and fundamental part of the love and intimacy between them. But for many others, sex fades into a boring and infrequent routine or it just doesn’t happen at all. And that’s not a happy place to be.

For many couples, sex—or the lack of it—becomes the white elephant in the room. They ignore; they avoid; they work around it. But generally, it’s an underlying irritation and cause of increasing anger, frustration, and dissatisfaction. Whether lack of sex is the cause of these emotions or is collateral damage caused by other problems becomes hard to tease out. Just the fact that the darned elephant is sitting there on the couch takes a lot of energy to ignore.

Relationships without sex are common—it’s estimated that from 20 to 30 percent of marriages are sexless, which is roughly defined as having sex 10 times per year or less. Even though women tend to struggle more with libido during menopause, “women don’t have a corner on low libido,” says Michele Weiner-Davis, therapist and author of The Sex-Starved Marriage in this very worthwhile Ted talk.

The number of times couples “do it” per year isn’t the point. Really, who’s counting? It’s the level of contentment and connection between them that counts.

“If a couple is OK with their pattern, whether it's infrequent or not at all, there isn't a problem," says clinical sexologist Judith Steinhart in this article. “It's not a lack of sex that's the issue, it's a discordant level of desire.”

And that discordant level of desire—when one partner wants sex and the other doesn’t--can cause deep, relationship-destroying pain.

We’re hard-wired for connection. We crave intimacy and emotional safety within our committed relationships. And sex is a powerful intimacy-builder.

But when it becomes the sole task of one partner to ask for sex, and when he or she is frequently rejected, a hurtful dynamic is set in motion. More is at stake than a roll in the hay. One’s self-worth and sense of being attractive to, connected to, and cared for by a lover is on the line. In research studies, that kind of rejection activates the same parts of the brain as physical pain.

Over time, repeated rejection morphs into anger, frustration, and contempt—or withdraws into boredom. Communication and connection on other levels shut down. Intimacy flattens like stale beer. We all know couples who don’t touch or make eye contact, or share a joke.

With discordant levels of desire, the person with less need for intimacy controls the relationship, says Weiner-Davis in this article. The bargain goes like this: “I am not into sex. You are. But I don't have to care about your sexual needs. Furthermore, I expect you to be monogamous.”

Besides being unfair, the fatal flaw of this unspoken agreement is that relationships are built on mutual caretaking, and when that falters, the essential contract begins to crumble. Sex in a loving relationship is a reaffirmation of that mutual caring—a giving and receiving of pleasure, intimacy, and trust. That’s what we all deeply long for, and if it goes away, we deeply grieve its loss.

So, whether you’re the withholder or the seeker in your relationship, there’s good news. Even couples in long-term relationships can reignite the flame. “It’s never too late to have a passion-filled marriage,” say Weiner-Davis. That doesn’t necessarily mean shades of gray, sex on the kitchen table kind of passion, but it does mean a renaissance of sexy touch, playfulness, cuddling, and general “canoodling,” says Foley.

For starters:

• Explain how you feel. Often, the partner with a lower libido doesn’t understand the hurt caused by rejection and lack of physical intimacy. Explain how much you miss the physical expression of love in your relationship. That it’s painful to feel he or she isn’t interested in being close to you. That you don’t want to settle for parallel, unconnected lives. That sex is important.
• Just do it. If you’re the low-libido partner, sometimes, you just have to get started in order to feel desire. If your partner clearly needs a little cuddle time, seize the opportunity to please and affirm your partner, whether you feel like it or not. If you can’t get into the mood, you can touch, kiss, and pleasure your partner in other ways—masturbation or oral sex, for example.
• Get creative. Familiarity and routine can be a serious buzz kill in a long-term relationship. Sometimes, mixing it up a little reignites the spark. Maybe recall the moves that used to turn you on or maybe take a midwinter break for a rejuvenation weekend. Be new lovers for each other.
• Get a physical. We all slow down with age. This isn’t problematic in itself, but if the slowing is one-sided or if either or both of you want more action between the sheets, then a complete physical workup should be one of your first steps—for men and women. Sexual functioning is linked to so many physical and emotional variables—medication, stress, depression, illness—that teasing out the possible intersections is a job for the professionals. Once they’re diagnosed, sexual issues can usually be treated or improved.
• Get counseling. Maybe you need a few sessions to jump-start communication. Maybe you need a deeper dive to unearth ingrained bad habits. Counseling, group therapy, a marriage retreat or some other reset might help address blind spots and self-defeating behavior. If your partner doesn’t want to go, you should go alone. "Counseling can help you figure out strategies to help yourself," says Sallie Foley, director of the Center for Sexual Health at the University of Michigan in this article.

Tackling a sexless marriage isn’t easy. Even if the status quo is unsatisfactory, changing it is risky and uncomfortable. If you’re continually gnawing on irritation; if you feel rejected and unattractive to your partner; if you’ve shut down and settled for boredom, it’s time to rattle that cage, express your feelings in a loving way, and actively seek out help.