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You asked. Dr. Barb answered.You describe your experience as “incredible pressure and pain,” and “deep aching pain.” You also said that you’ve had some varicose veins in your legs and have had some removed. Your research led you to vulvar varicosities, which does sound like a possible answer. These are varicose veins in the vulva, which are not all that common but do occur (often during pregnancy).

There are two options I’d like you to consider: The first is a good pelvic floor physical therapist. She or he can assess structurally whether there is evidence of a source for your pain. A great therapist can work magic! Really, they can.

The second option is a vein specialist. They can do an ultrasound assessment of vein function, even in the vulva, and try to help understand if that is what might be causing your discomfort.

Good luck on your journey!

One of the benefits of my work with MiddlesexMD is the networking that makes it more likely that I’ll run into medical information, over-the-counter products, articles and books that could be helpful to my patients, and, of course, the interesting conversations that turned into our podcast, The Fullness of Life.

Love Worth Making book coverI received an advance copy of Love Worth Making: How to Have Ridiculously Great Sex in a Long-Lasting Relationshipby Stephen Snyder, MD, a month or so ago. Steve is a couples therapist, psychiatrist, and writer, as well as associate clinical professor of Psychiatry at the Icahn School of Medicine at Mt. Sinai in New York City. While I’ve met him—so far—only via email and his written words, I know we share some perspectives: that intimacy remains important to us no matter what our age, that men and women do have some differences in their approaches to love-making, and that there’s nothing wrong—and lots that’s right—about seeking tools that help us!

I think it’s useful to hear men’s perspective on sexuality, too, so when Steve offered to contribute to this blog, I accepted! Read on for more from Stephen Snyder, “sex therapist in the ‘hood.”

Several years ago, a merchant in my neighborhood learned that I was both an MD and a sex therapist. The next time I was in his shop, he asked me if I could get him some Viagra.

“How long have you had erection problems?” I asked.

“I don’t,” he answered. “But my wife and I have been married for 30 years. To tell you the truth, sometimes I’m too tired or preoccupied to get hard without the Viagra.”

What was this man’s problem, exactly? He wanted to have sex with his wife, even though he wasn’t feeling that strongly turned on. Evidently there were other reasons he wanted to do it.

Sound familiar? Of course: He wanted to make love like a woman.

Things women take for granted about sex

Women can have sex with their partners any time they want. They don’t have to be very excited. Sure, some lubricant might be required, especially over 50. But the absence of peak excitement isn’t necessarily a deal-breaker.

A woman can make love for other reasons besides strong desire. To feel close or emotionally connected to her partner. To promote loving feelings. Or just for the simple pleasure of the experience. Even occasionally to keep a partner happy, even though she might be too tired or preoccupied to be really into it. A useful book on the subject calls it “good-enough sex.”

One wouldn’t want all one’s sex experiences to be like this. But once in a while it’s okay.  Especially if the alternative is not to make love at all. If there’s one thing that sex research repeatedly shows about successful long-term couples, it’s that they keep having sex even when if the sex isn’t always earth-shaking. The ritual itself is important.

Men traditionally haven’t been able to do sex very easily under conditions of lower arousal.  Especially over 50, when it ordinarily takes more stimulation to stay hard than it did at 20. If a man, for whatever reason, hasn’t been strongly turned on, conventional sex hasn’t usually been an option for him.

Viagra changed all that. Since the blue pill came on the market in 1998, a man can take Viagra and have sex even if he’s tired or preoccupied and just wants some loving and affirmation but isn’t feeling peak excitement. In fact, just having a good erection can help a man feel more in the mood.

Is Viagra good for sex?

There is often strong partner resistance to a man’s boosting his erection through chemistry, though. Women especially are used to the affirmation that occurs when a man gets hard (as Mae West famously put it) simply because he’s “happy to see her.” It’s worth it for a man to communicate that he needs sex for closeness and affirmation and pleasure as well. Just like she does. And that worrying about his erection just gets in the way.

Some couples worry whether taking Viagra under such conditions is a wholesome or natural thing to do. If it just takes more sexual stimulation now to keep him hard, wouldn’t it be more natural to simply intensify the excitement?

Maybe, but not necessarily. Intensifying excitement sounds like a great idea. But in practice, having to do things to get the man hard enough can be a bit of a burden. And it can take time, sometimes so much time that the moment is lost.

Sound familiar? Of course. It’s the same predicament that women find themselves in when they can’t get lubricated or can’t climax. Deliberate efforts to manufacture excitement often backfire. They usually aren’t very erotic.

My advice? It depends on the couple and the situation. But sometimes Eros is best served by taking the Viagra. Then a man can stop worrying about his erection, and get back to making love.

Sometimes it’s best for a man once in awhile to make love like a woman.

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 estrogenOsphena,  or Intrarosawould 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.

You asked. Dr. Barb Answered.The loss of hormones (estrogen and testosterone) with a hysterectomy and bilateral salpigoophorectomy (removal of ovaries) is definitely a “hit” to sexual function for women (I assume based on your message that your ovaries were removed). The genitals are, as we say in medicine, abundant with hormone receptors. In other words, hormones play a big role in the health and function—both urinary and sexual—of the genitals. So now, moving on without those hormones, what to do?

For most women, it’s direct stimulation of the clitoris that leads to experiencing orgasm. In the absence of estrogen, there is less blood supply, and, in turn, loss of sensation and ability to arouse or orgasm.

  • You can use a device to counter this trend. The Fiera Arouser is a small device you use before intimacy. It uses vacuum to increase circulation—and therefore sensation—in your clitoris.
  • There are also warming lubricants that can accelerate your response by increasing, again, circulation.
  • If your orgasms are weak, you might use the Intensity regularly on your own to build your pelvic floor muscles, which are what enable us to experience orgasm.
  • Probably the most reliable tool to help in achieving an orgasm will be a vibrator. The genitals need more direct and intense stimulation now, and a vibrator is usually a great solution. There are many great options to consider on the website.

This can also be a time to consider treating the genitals with prescription treatments such as localized estrogen or the non-estrogen options, Osphena or IntrarosaUsing testosterone off-label can help women with arousal and orgasm as well.

I’d encourage a conversation with your healthcare provider to see if there are options that may be helpful for you.

Good luck! I’m glad to hear that your husband is supportive in addressing this frustration for both of you!

I’m so sorry that you’re experiencing this loss in your relationship. Both depression and the medications used to treat it can be culprits in a loss of desire, and given the relatively short time frame in which you noted the change (one or two weeks), the antidepressant is the likely explanation for your husband.

The situation that you describe is probably best addressed with the help of a therapist; someone who does sex therapy would be most helpful (you can find one certified by the American Association of Sexuality Educators, Counselors, and Therapists through their website).

You asked. Dr. Barb answered.As you’ve begun to experience, the longer this dynamic goes on, the more anger and resentment builds. Having a therapist to help you navigate the conversations is extremely helpful. And your suggestion of a therapist sends your partner the clear message that intimacy is really, really important for you and your relationship.

There’s some evidence that Stronvivo, a nutritional supplement for cardiovascular health, can improve both libido and function in both men and women; that could be a consideration as well.

Good luck!

How We Get Turned On

The Female Sexual Response Cycle

As we’ve said (many times) before, our sexual responses are complicated and unpredictable. And this becomes especially true once we’ve embarked upon this menopausal transition. That doesn’t mean we can’t respond sexually anymore, just that we respond differently from men and differently even from the way we did before.

Way back in the 1960s, Masters and Johnson, the groundbreaking sexologists, developed a graph of the sexual response cycle. It was a simple, linear depiction that purported to track both men and women from arousal to afterglow in four stages—arousal, plateau, orgasm, and resolution. Sort of like a visual depiction of the wham-bam-thank-you-ma’am version of sex that women used to think was normal.

It did not contain a lot of room for nuance.

Fortunately, concepts about how we respond sexually have evolved over the years. Lately, Rosemary Basson, professor of psychiatry at the University of British Columbia, proposed another model of how women, specifically, experience sex. Guess what? It’s different from men. Her graph is circular. It includes elements that previously weren’t linked to sex, like relationship satisfaction and self-image, and our previous sexual experiences. It leaves room for skipped steps and a non-linear response to sex. This woman gets us.

Take feeling desire, for example. Basson’s model doesn’t get all hung up on desire. You may not feel spontaneous desire—the old “horny” thing—the way you used to. Or maybe you’ve never felt horny. According to a 1999 study from the University of Chicago, fully one-third of women never feel desire. “[Women] may move from sexual arousal to orgasm and satisfaction without experiencing sexual desire, or they can experience desire, arousal, and satisfaction but not orgasm,” according to this article.

You may not feel desire until you’ve begun to have sex; you might not feel desire even then. You might not feel desire even if you orgasm.

Likewise, for a lot of us, sexual satisfaction doesn’t even depend on having an orgasm, necessarily. We may have lovely, satisfying sex because it satisfies our partner and affirms the relationship and enhances our feeling of intimacy. Or, we may engage in sex for negative reasons, such as not wanting to lose a partner or avoiding the unpleasantness of turning him down.

Basically, Basson’s work tells us that however we experience sex that works for us and our partner is good sex. We may not “feel like” sex (experience desire), but once we get into it, desire might come tripping along like a puppy on a leash. Or, it might not, but the sex might be good anyway.

According to the literature, the sex that seems to work best for most couples is light-hearted, flirty, playful sex. It isn’t rushed. It has nothing to prove. It’s a mature, evolved celebration of the fact we’re still here, still loving each other. It’s the kind of sex worth working for.

Couple in kitchenSo, let’s give ourselves a break. If we’ve been honest with ourselves, our sexual response very often depends on stimuli that has little to do with sex—how safe and happy we are in our relationship; how long we’ve been in the relationship; how we feel about ourselves (confident, sexy, desirable; or fatigued, stressed, distracted); whether sex has been painful (it’s hard to look forward to an experience that’s associated with pain).

The most important thing that’s necessary for sexual satisfaction in your relationship is the willingness to pursue it in whatever way works for you.

Oh, and the more sex you have, the more you want it. There are lots of ways to make sex comfortable after menopause: That’s what this website is all about; lube up and laissez le bons temps rouler.

 

What you describe—pain during intercourse and tissues that your doctor says are thinning and pale—sounds like vulvovaginal atrophy, also called genitourinary syndrome of menopause (GSM). Since your hysterectomy (if it included your ovaries) or whenever your ovaries stopped producing estrogen, your vaginal tissues have become more fragile and can actually tear. GSM is what we call chronic and progressive, meaning it will continue to get worse over time as a natural consequence of the loss of hormones. If you want to have comfortable intercourse, you’ll need to maintain a treatment plan.

The most likely effective treatment is localized estrogen (in creams, ring, or tablet) or Osphena, a non-estrogen oral medication, or Intrarosa, a non-estrogen vaginal insert. Those are all prescription therapies. If you don’t have access to prescription medications, or in addition to them, vaginal moisturizers can be of some benefit; I’d recommend PrevaLeaf Oasis.

PrevaLeaf Oasis MoisturizerYou say that your partner is sometimes away from home for weeks or months at a time for military service. That can also pose some challenges for you. At this point in our lives, we face a “use it or lose it” challenge with our vaginal tissues, circulation, and muscle tone. That means treating your GSM can’t be an off-and-on pattern; you need continuous maintenance. I published an article shortly after MiddlesexMD launched called “Vaginal Patency for Single Women.” While you’re not single, you might follow some of its advice, including the use of a vibrator during those “dry spells” when you’re home alone.

Best of luck in regaining not only comfort but pleasure! Intimacy is an important part of our relationships and our lives.

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