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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.

It’s no wonder we’re confused. First it’s good; then it’s bad. Now it’s up to you.

Hormone replacement therapy has had more media makeovers than Liz Taylor, and it continues to grab attention here and there.

The latest, and highly credible, statement on the issue is from an international roundtable of medical experts convened by the Society for Women’s Health Research (SWHR). The purpose of this gathering of experts, which represented various specialties, such as cardiovascular disease, osteoporosis, and cancer, was to take yet another objective and rigorous look at the evidence regarding hormone replacement therapy, and to make recommendations as to its use and safety. The results of this discussion just came out in the Journal of Women’s Health.

This roundtable is a good effort to shed some objective light on the risks and benefits of an issue that’s been hotly debated for over ten years now, ever since the Women’s Health Initiative (WHI) prematurely ended its groundbreaking study of women receiving hormone therapy in 2002 because of a high incidence of breast cancer and cardiovascular complications.

The problem, however, is that hormone therapy (HT) is still the only effective, FDA-approved treatment for menopausal symptoms, such as hot flashes and vaginal changes. Recently two non-hormonal drugs were just nixed by an FDA advisory panel because they were viewed as ineffective.

Ever since the WHI results were released, the pendulum has been swinging wildly with each new medical release or research report. And while this latest SWHR roundtable really moves the chess pieces very little, it does solidly reaffirm positions held by the North American Menopause Society.

(In fact, NAMS had released its latest position statement on hormone treatment barely a month earlier.)

What the roundtable did add, however, is something I strongly advocate: Give women solid information about their treatment options and let them make informed decisions about their own health.

Their findings include:

  • In younger, postmenopausal women with menopausal symptoms, the benefits of HT outweigh the risks;
  • HT is the most effective treatment for osteoporosis and should be considered for the prevention of osteoporosis, especially among at risk women;
  • Contrary to popular misconceptions, HT for early, postmenopausal women does not increase the risk for coronary heart disease (CHD) and may even reduce it;
  • HT does not increase total mortality rates and may, in fact reduce them.

Here’s how the SWHR roundtable puts it: “It’s time to put HT back on the table so that women can discuss with their providers the option of symptom relief and possible long term health benefits.”

Amen to that.

Whether you’re using a cream, tablet, or ring to add localized hormones to your vagina, your partner is not absorbing any—no more than he did when you were producing your own hormones before menopause. You (and he!) can feel perfectly confident about your use of these products, and your intimacy will benefit from the increased comfort you’re likely to experience.

In the beginning, there was passion. Your feelings were almost painful. You wrote long letters and sent silly gifts and spent hours in whispered conversations on the phone. A lifetime ago. Remember?

Then came the long familiar years. You settled into a cozy, secure routine. You finished each other’s sentences; you knew the next move, the habits, the vulnerabilities, the quirks and preferences.

But what happened to the passion?

Psychotherapist Esther Perel has spent her career studying the sexual language of long-term, committed couples. She’s pondered the dynamics of the love/desire dialectic, and she’s identified the qualities that keep the sexual spark alive over the years. In a recent talk, she discussed her work with exceptional lucidity. You may intuitively know what Perel has to say, but few of us have articulated it so clearly. In any case, it’s good to be reminded—and challenged.

Desire and love are paradoxical. They’re mutually exclusive. Love, says Perel, is to have. It’s associated with security, with safety, with roots and foundations. To love is to know the beloved and to be known. But this contented intimacy isn’t a necessary component of good sex, “contrary to popular belief,” says Perel.

To desire, on the other hand, is to want. Desire craves adventure, novelty, risk. We desire mystery, the unattainable, the 50 Shades kind of guy.

Trouble is, we want both love and desire. We want security and passion. Intimacy and mystery. Safety and risk. So how can these opposing drives coexist in a marriage? How can we settle into the mature love of a long-term relationship without losing the hungry edge of desire that brought us together in the first place? How can we achieve the ideal of a “passionate marriage,” which fans the flame of desire within the intimacy of commitment?

As she studied couples around the world, Perel asked them when they found themselves most attracted to their partner. She heard variations of the same theme:

  1. When they reunite after an absence.
  2. When watching the other from a distance when the partner is completely engaged in an activity. “When I look at my partner, radiant and confident, [is] probably the biggest turn-on across the board,” says Perel.
  3. When there are no demands and no needs.  “Caretaking is mightily loving,” says Perel. But, “it’s a powerful anti-aphrodisiac.”
  4. When there is some novelty or newness. “When he’s in his tux,” said one person. Substitute cowboy boots, or a toolbelt, or motorcycle leather.

In these situations, there is a shift in perspective from the familiar to a sense of separation and distance. It’s the Proustian “voyage of discovery [that] consists, not in seeking new landscapes, but in having new eyes.”

Desire is a dialog we have with committed love. It’s a duet, a dance. The dynamic may be paradoxical, but both are necessary if a long-term relationship is to remain vital. It’s the language of poetry and mystery rather than of process and technique. Desire is more complex than bedroom gymnastics.

From her experience in studying and counseling couples, Perel has distilled several qualities that erotic couples seem to have in common. These aren’t on many “how-to” lists; they have more to do with essence than with activities. They may not be easy to incorporate because they’re not as straightforward as establishing a “date night.” But the concepts she delineates are worth some thought.

  1. Give each other some erotic privacy. Maybe this is the space that preserves mystery. It allows the other some personal freedom to explore. It acknowledges that you aren’t joined at the hip; that there is difference and distance. “Erotic privacy may mean different things to different people,” writes Pamela Madsen, author of Shameless. “It may mean the privacy to look at pornography and not share some desires with our partners. It may mean the possibility of exploring ourselves within agreed upon boundaries without our partners.”
  2. Foreplay isn’t optional. It isn’t a five-minute, pre-sex duty. “Foreplay pretty much starts at the end of the previous orgasm,” says Perel. These relationships cultivate a sense of erotic anticipation.
  3. Check the “good girl” at the door. Desire is selfish. You aren’t responsible for organizing or orchestrating. “Responsibility and desire just butt heads,” says Perel.
  4. Passion has seasons. Like the moon, it waxes and wanes. It will return, but keep on having sex in the meantime. “Willful, non-spontaneous sex,” says Madsen.

“Committed sex is premeditated sex,” says Perel. “It’s willful. It’s intentional. It’s focus and presence.”

To hear Perel’s talk in its entirety, visit the TED website here. This twenty minutes may be the best gift you could give your relationship today.

A burning sensation in the vaginal and vulvar area can be a symptom of vulvovaginal atrophy, which occurs as estrogen levels decline. Premarin cream or other localized estrogen can reverse those atrophic changes; it typically takes weeks of use for full effect.

If the burning sensation is in or extends further back, toward or including the buttocks, it’s likely not vulvovaginal atrophy. It could be, instead, a nerve condition. Shingles, unfortunately, can happen in this area; there are other pelvic floor conditions—like scarring or injury—that can affect nerves. A careful pelvic exam can help to determine exactly what’s happening.

I encourage you to talk to your health care provider—and again, if you’re not seeing improvement!

I never knew what it meant to prime a pump until I watched a plumber work on one at my cottage. To prime a pump means to pour a little water into its fill cap to create suction and, with luck, to pressurize the thing so it draws water rather than spurting air.

The hydraulics metaphor may be more appropriate for men, but I’m betting that some of your orgasmic pressure has leaked out over the years, too. Or, maybe it wasn’t very dependable to begin with. According to some studies, from 25 to 50 percent of women have trouble achieving orgasm.

There are, however, ways to repressurize your orgasmic system—techniques that may help get the sexual juices flowing again. It’s not magic—there is still no pink Viagra that guarantees an orgasm, given that the female sexual response cycle is a lot more complicated than a water pump.

If your orgasmic mechanism needs a little priming, here some holistic ways to repressurize.

  1. Exercise. (I heard that groan.) Good orgasms require good circulation to keep all that oxygenated blood flowing to your genitals. Aging does a number on the blood flow and nerve endings in the genital area, making them sluggish and less responsive.  Exercise helps maintain good circulation. It also keeps blood circulating nicely to the brain, which, as we’ve said, is really your biggest sex organ.
  2. Kegels. C’mon. These are easy and painless (there are tools available), and they do you a lot of good. Kegels tone and strengthen your pelvic floor muscles; those muscles keep you from leaking urine when you sneeze as well as holding your internal organs in place. Strong pelvic floor muscles also create a firm “vaginal embrace,” which is nice for your man, but also gives you a more powerful orgasm.
  3. Check your medications. Several categories of drugs are libido killers, including some antidepressants, but also some drugs that reduce cholesterol and high blood pressure. If you suspect that your meds may be messing with your sex drive, talk to your doctor.
  4. Masturbate. You need good circulation down there, right? Self-pleasuring helps. It also helps you identify what you like and how to “do it” the way you like it—so you can tell your partner.
  5. Get a vibrator and other sex toys. There are all sorts of physical reasons to use a vibrator. (See #4 above.) Toys may help you release some inhibitions and learn to play.
  6. Drink a little (not a lot.) Sharing a little pre-sex cocktail can create a cozy sense of intimacy and also help lower your inhibitions. Drinking too much is a libido-killer. Share a glass of wine in front of the fireplace and move the action to the bedroom—or keep it by the fireplace.
  7. Fantasize. Think of it as your personal romance novel. You can sleep with anyone you want and do anything you want. You’re only limited by your imagination. Fantasy helps some women “get into their heads.” Try it.
  8. Positions. If you’ve been using your vibrator, you know where your sweet spots are, and the missionary position often misses them. Try the back entry “doggie-style” position which is good for hitting the G-spot, although not so good for the clitoris, or try sitting on his lap, which is good for all kinds of things.
  9. Foreplay. If you take seriously Esther Perel’s statement that, for erotic couples, “foreplay pretty much starts at the end of the previous orgasm,” you may extrapolate that good sex arises from consciously introducing sensuality into your relationship in a sustained way. Touch. Snuggle. Sextext. Write love notes. Introduce beauty and sensuality into your life that might leach into lovemaking as well.
  10. Have sex. This cannot be repeated too often. The more you have it, the more you want it, and the better at it you become. As one happily married husband said: “Practice, practice, practice.”

Most women have very normal sexual function without a cervix. I have seen reports that suggest an issue, but in 24 years of practice, I can’t recall a single woman who was impaired by the absence of her cervix.

There are complications that result if the cervix is left after a hysterectomy, including abnormal pap smears and continued bleeding. If there is any remaining endometrium (the membrane lining of the uterus) and you consider hormone therapy in menopause, you will need progesterone as well as estrogen. I’ve seen women less fond of progesterone than estrogen.

Whether you’re able to keep ovaries in a hysterectomy is a bigger issue to sexuality—and in fact overall health—for women. Even after menopause, the ovaries continue to produce hormones. Those hormones not only mitigate some of the effects of menopause, but they also promote bone and heart health. There are times when it’s appropriate to remove the ovaries as part of a hysterectomy, but the decision needs to be made based on each woman’s health and history.

Glad you’re thinking about your continued sexual health, and good luck with your recovery!

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