Occasionally we post about women who have come before us who helped make frank conversations about women’s sexuality possible. Certainly, the way we feel about ourselves affects intimacy. That’s why we want to express appreciation for Cindy Joseph, a model and entrepreneur who redefined beauty in midlife by being an advocate for aging authentically.
In her obituary, the New York Times called her “a model who embraced her age” but before she was discovered on a New York city street by a casting agent at the age of 49, she was a professional makeup artist. She worked with super-models including Cindy Crawford and Naomi Campbell.
“It was difficult to spend days with these girls and feel good about myself,” she said. “I knew deep down, however, that there was more to attractiveness than shiny hair and big eyes.” Over time, she noticed that “surface beauty was fleeting” and the models were the most beautiful when they were truly enjoying their lives. After that, she was no longer intimidated by what she calls “their package.”
She modeled into her sixties for clients like Elizabeth Arden and Ann Taylor. In 2011, inspired by the realization that every cosmetics company was anti-age, she started Boom! Based on Joseph’s belief that women can look beautiful without looking younger, Boom! offers sheer cosmetics with the goal of burnishing a woman’s features rather than masking them.
“Aging is really just another word for living,” she wrote. “The concept that aging is becoming less in some way is really the antithesis of what happens. One becomes more and more as life continues. I am always and forever in the ‘prime of my life.’”Joseph died on July 25, 2018, at the age of 67.
There aren’t surgical options to restore genital sensation.
Exercise is a critical component of overall wellness (see this blog post on the topic). Exercise improves energy and self-esteem, releases helpful hormones, and does more that translates into improved sexual health and function.
Hormone therapy absolutely improves loss of sensation. The genitals have more estrogen receptors than any other area of the body, which means that the impact of estrogen is greater in the genitals than in any other area of the body! So especially in menopause (or other times of low estrogen), hormones are a big ingredient of sexual function. Testosterone is an important hormone for arousal and orgasm as well. You asked whether estrogen or testosterone “matters most”; while it’s hard for me to choose, I incline toward estrogen. I usually start patients with estrogen and add testosterone if it seems necessary or appropriate.
That said, we know a loss of sensation is a natural part of aging, as well as with chronic diseases such as heart disease or diabetes, and it can be a side effect of medications. That means for each individual, countering that loss is a bit more complex than a single simple answer. For many women, vibrators work wonderfully to heighten sensation. Warming lubricants also increase sensation; they have minty or peppery ingredients that stimulate circulation.
It’s worth trying a few options to see what works for you!
You say that penetration is becoming increasingly difficult, although you’re using lubricants. This is normal progression: In the absence of estrogen due to menopause, our genitals atrophy. The vulva and vagina get smaller, the vagina narrows, there’s a significant loss of volume of the genital tissues, including the clitoris. There are fewer folds in the vagina (I’ve talked about a transition from a pleated skirt to a pencil skirt to give an idea of the change in elasticity). The tissues become thin, pale, dry, and fragile, and the pH level changes.
These changes are what we in medicine consider to be “chronic and progressive,” so without treatment, there’s no question that the changes will continue. The most basic “treatment” is regular sex or external and internal use of a vibrator (if you don’t have an available and willing partner), which improves blood supply to the area and restores some comfort and tissue health. Using a vaginal moisturizer daily or at least twice a week can also help somewhat to keep tissues healthy.
There are also prescription therapies that are designed to really reverse the atrophy. They are all very effective. They include localized estrogens, the oral non-estrogen Osphena, and now, the newest, the non-estrogen daily vaginal insert Intrarosa. A discussion with your health care provider would be very helpful to determine next steps.
Sometimes the use of dilators can be helpful to stretch the vaginal tissues to maintain capacity. But without prescription treatments like those listed above or, possibly, systemic hormone therapy, the tissues are not very elastic, which limits the degree of stretch you can obtain.
With some investigation and follow-through, you can “keep the shop open”!
Many of the intravaginal moisturizers (like the Lubrigyn you mention) will correct or “normalize” the vaginal pH. (An atrophic vagina has a more “basic” pH, and a healthy vagina is more acidic.) Use of a moisturizer will cause a transition of the pH to a more health status, which is a shift of bacteria; you’ll end up with more lactobacilli, which is a good thing.
But whenever we make a shift, the time of transition is a bit of risk for a yeast infection. This is not an adverse effect of the product, but more likely indicates that it is making a difference. Go ahead and treat the yeast infection, and I’d recommend continued use of Lubrigyn. This shouldn’t be a recurrent event once tissues are healthier.
While reflecting on our anniversary a few years back, we were reminded of how many women have come before us, paving the way for straightforward conversations about women’s sexuality. We don’t see any reason not to keep adding to the series (read the first, second and third) meant to express our gratitude to them!
Patricia Schiller’s parents wanted her to be a teacher. And while she eschewed a degree in education for degrees in law and, later, psychology, she did end up teaching an entire generation, becoming “a leading voice in sex education and counseling.”
As a lawyer in the 1950s, it occurred to her that couples needed counseling more than the legal advice she was offering them. She returned to school and earned a masters degree in clinical psychology from American University in 1960.
In 1963, a time when pregnant teenagers were expected to drop out of school and did, she helped launch the Webster School, which gave pregnant girls the opportunity and support needed to finish their educations.
She also was a founder of the American Association of Sex Educators and Counselors, helping to establish standards for the profession. At the same time, she was changing the conversation about sex education. One of her goals was to make it acceptable to talk about sex, which she saw as being about more than just the act of sex. To her it was “a function of being human” and something that could lead to people becoming “warmer, more caring.”
Sex education should reflect that idea, she felt. In her book Sex Questions Kids Ask—and How to Answer, which she published in 2009, she wrote “sex education can teach children what it is that makes a mother or father sympathetic, understanding and respected.” She wrote two other books (Creative Approach to Sex Education and Counseling and The Sex Profession: What Sex Therapy Can Do), as well as many articles for professional journals.
People often joked about Schiller’s profession, saying things like “there’s the sex maniac.” “But I don’t mind,” she once told The Washington Post. “I enjoy it.” She died on June 29, 2018, an educator to the end.
If the title of this post pulled you in, you’re likely part of the almost 50 percent of women aged 40 to 64 who have sleep problems. I’m sorry you’re a part of this club, but welcome! Sleep has been in the news a lot since—well, for as long as I can remember. It affects everything from mood and willpower to productivity and relationships. We all know how hard it is to gin up enthusiasm for romance when we’re sleep deprived.
Sleep also has implications for long-term health. Research shows that not getting enough sleep can lead to serious issues like diabetes and cardiovascular disease and a weakened immune system.
The evidence that we should make sleep a priority is pretty compelling. Perhaps you took the advice of our recent post on good sleep hygiene, and you have been going to bed at the same time every night, avoiding food, exercise, and alcohol several hours before bed, and keeping your bedroom cool and dark. Well done!
But if you’re still reading, those good habits may not be paying off for you. There are few things more frustrating to my patients than knowing all the reasons good sleep is important, following all the advice—and still not getting good sleep.
If you’ve tried all the normal ways to fix your sleep problems, and you don’t want to try medication, you might want to experiment with natural remedies.
As I’ve said before, herbal supplements are generally considered foodstuffs in the U.S., so manufacturers don’t have to conduct clinical studies about their efficacy or side effects. I can’t necessarily vouch for them, but few are known to be harmful. Some patients report one supplement or another has worked for them, and maybe one of them will work for you, too.
If you do want to try one, first consult with your doctor to make sure it’s safe for you, given your health and the medications you’re taking. I also recommend that you keep a sleep journal for a week before you begin and for 12 weeks after. Make a note of sleep hygiene factors, too, like when you ate and exercised and put away screens for the night.
Melatonin is a hormone that regulates when we sleep. When melatonin levels rise at night, body temperature falls and we feel sleepy. Melatonin seems to be most effective at helping people fall asleep rather than stay asleep. Calcium aids in the production of melatonin, which may be why some people find that drinking a glass of warm milk before bed makes them sleepy.
L-theanine is an amino acid that increases brain chemicals that are calming and reduces brain chemicals linked to stress and anxiety. Rather than acting as a sedative, L-theanine can improve the quality of sleep by lowering anxiety. It’s most often found in tea but can be bought in the form of supplements.
Valerian is an herb. Valerian root is thought to reduce anxiety by acting as a sedative, but research results on that have been mixed. It may help you fall asleep more quickly and improve the quality of your sleep, but you might need to use it every day for up to four weeks before it starts to help.
Magnesium is a mineral. Most adults get enough of it through their diets (leafy green vegetables, nuts, and whole grains are good sources), but it might affect the sleep of those who don’t; magnesium deficiency has been linked to higher levels of anxiety, which interferes with sleep. If you suspect you are low on magnesium, eat more of the above. Magnesium supplements often don’t play nicely with medications.
Lavender is a popular natural sleep remedy. Many people say just the smell of it relaxes them and makes it easier to sleep. There is some research that shows that taking lavender oil by mouth for 6 to 10 weeks reduces anxiety and improves sleep.
Lavender—or any of the natural remedies above—may really work for some people. Or perhaps it’s just the placebo effect. If something is safe and it helps a patient get better sleep, I don’t care much about whether it’s “real” or placebo. And I suspect that you don’t, either.
Have you tried any of these or another that we haven’t included? I’d love to hear what’s working for you!
You say you’re using a vaginal suppository for vaginal moisturizing; the product you’re using contains illipe butter, coconut oil, vitamin E oil, apricot oil, meadowfoam plant wax, and carnauba plant wax. If you’re tolerating this product well, and it’s working for you, great!
It’s hard to determine in advance which products will work for which women. For some women, oils can be somewhat occlusive and cause tissue breakdown. For others, oils increase risk of vaginal yeast infections. Other women can be sensitive to specific ingredients, like coconut and certain fragrances.
Feel comfortable with what works for you, and keep in mind that your body changes over time, too—which may mean you’ll need to rethink your routine.
Yes, shortening of the vagina is a possible consequence of a hysterectomy, and that is clearly what you are describing. You say you were previously using an Estring vaginal ring to address menopausal symptoms; the Estring won’t work for you now, since having it inserted is uncomfortable. Oral HT isn’t an option for you because you’re a breast cancer survivor.
Please don’t lose heart. I’d recommend you consider using Intrarosa, a newer, very effective treatment for postmenopausal atrophy. It is a nightly vaginal insert, non-estrogen. Osphena is another non-estrogen oral option, or you could use a cream form of vaginal estrogen. Any of these is likely to be an effective treatment option, and all of them are considered safe for breast cancer survivors.
After restoring health to the vagina, you may then need to use vaginal dilators. Dilators are designed to increase vaginal “capacity,” whether in width or (as in your case) length. A healthy or “estrogenized” vagina should be distensible and elastic to get back the necessary length. Most women are very successful in regaining this function.
Once again the yin/yang of hormone therapy (HT) is in the crosshairs. On the one hand, estrogen is the only truly effective treatment for vasomotor symptoms (hot flashes) during menopause. Estrogen also helps ease vaginal dryness, night sweats, and sleeplessness. It protects against osteoporosis and lowers the risk of heart disease. On the other hand, if you have breast cancer, estrogen may promote the growth of the cancer cells. Oral estrogen may increase the risk of stroke (although transdermal estrogen therapy doesn’t pose this risk).
This risk/benefit ledger has been totted and rejiggered for years as research adds to one column and subtracts from another. Overall, and with a few caveats, the level of risk inherent in HT is fairly low for the benefits conferred. Recently, however, a second iteration of a large Finnish “observational” study points to a new risk.
The study, which examined death records mandated by the government of Finland of over 300,000 women, found that postmenopausal women under age 60 who stopped HT were at statistically significant risk of death from heart attack and stroke in the first year after they stopped treatment. This elevated risk of cardiovascular death wasn’t found in women over age 60. And after the first year, these risks return to normal levels.
“This new study suggests that younger women may have a higher risk of heart disease and stroke during the first year of discontinuation,” says Dr. JoAnn Pinkerton, executive director of the North American Menopause Society (NAMS). “Thus, women and their healthcare providers need to consider the benefits and risks of starting and stopping hormone therapy before making any decision.”
Sobering, but let’s get some perspective. While the study’s results were fairly well-accepted, the data leaves some important questions unanswered: Because the data were drawn from government medical records, researchers weren’t able to determine whether women stopped HT abruptly or tapered off; they also couldn’t determine what dosages the women were taking or how the estrogen was delivered (pill or patch), which are areas that could affect outcomes and that need more study.
While a direct cause-and-effect relationship can’t be conclusively drawn in this kind of study, research suggests that the withdrawal of hormone treatment may jump-start certain processes, such as a creating an inflammatory reaction or causing a constriction of blood vessels.
Whether to begin hormone therapy, for how long to continue, and when to stop is a risk/benefit analysis that involves many factors unique to you: the severity of your symptoms, your quality of life considerations, age, whether you’ve had a hysterectomy, and other risk factors, such as osteoporosis, breast cancer, and stroke, in addition to your own preferences.
NAMS still recommends HT as an effective treatment for hot flashes and other unpleasantries of menopause, but it also recommends that estrogen be prescribed at the lowest effective dose for the shortest possible time. HT is safer and more effective when it is begun under age 60 and within 10 years of menopause.
What this new research adds to the decision-making equation is the potentially elevated risk when HT is stopped before age 60, essentially adding yet another element to the already loaded risk/benefit equation concerning hormone therapy. While this information adds urgency to the need for a thorough discussion with your doctor before starting or stopping hormone therapy, it doesn’t really change the necessity of having one. Nor does affect the need to revisit the decision annually while you’re on HT.
It would be very, very unusual for an old episiotomy scar to become problematic. You say you experience dryness, irritation, and a “tearing feeling,” which sounds to me entirely consistent with vulvodynia (also called vestibulodynia or provoked vulvodynia). Other ways the pain has been described are “sandpaper,” “cutting,” or “ripping.” The most common experience with vulvodynia is pain with intercourse, and usually not with other activities (although sometimes women have sensitivity when wiping after urination). There may or may not be vaginal dryness.
If the pain you’re experiencing is related to atrophy, which is very common and usually evident by vaginal dryness, the Premarin vaginal cream you describe using should be quite effective for that. A topical steroid, which you’ve also been prescribed, would be helpful if there’s an identified vulvar skin condition or dermatosis, but I’m not sure any of your descriptions indicate that the steroid is beneficial. You also asked about the Mona Lisa Touch, which has been shown effective for atrophy, but not vulvodynia, at least thus far.
For patients with vulvodynia, I use a compounded prescription of low-dose estrogen plus testosterone applied to the opening of the vagina (the introitus) two times a day for 12 weeks, tapering to once a day or less. Another option might be Intrarosa, a relatively new treatment for vulvovaginal atrophy, which I’ve begun using with some vulvodynia patients. Intrarosa is a vaginal insert, used nightly; it’s metabolized to testosterone (and estrogen) in the vagina, so I think this is going to help vulvodynia.
Note that vulvodynia can be difficult to diagnose, because the vulva and vagina may look normal. Describing your symptoms accurately will be extremely helpful!