You describe two issues, one of which is painful sex and the other is embarrassing sound effects when your partner withdraws. You’re wondering why that happens and whether you can change it.

Vaginal DilatorsI don’t have an absolute solution for your dilemma, but I do have a suggestion that I hope will be helpful. We consider the vagina to be a “potential space”; in other words, the walls of the vagina are usually collapsed but can create “space” when needed – when you insert a tampon, for example, or during intercourse. When the space is created, air can, as you describe, enter and be trapped; the entering object (a penis, during intercourse) forces the air out. If the space is tight, there’s likely to be that sound effect you’ve noticed.

You may consider using vaginal dilators, which gently stretch the vagina, giving it greater capacity in both width and depth. This should both reduce the painful sensation of tightness you experience and the likelihood that air escaping will cause the embarrassing sounds.

I think this is definitely worth trying. Good luck! And in the meantime, remember that sex for everyone includes at least some messiness or awkwardness – and one of the joys of midlife intimacy can be the playfulness of laughing together.

You say you’ve tested negative for herpes 1 and 2 antibodies, while your partner has tested positive for the herpes 2 virus, though he has not shown symptoms. I don’t find your situation unusual, and it does pose a bit of a conundrum. The reality is that using condoms is the most reliable way to prevent transmission, but in a long-term relationship, I understand that it’s not desirable.

I find that the most up to date and reliable information regarding HSV (and other STIs) is the Centers for Disease Control and Prevention (CDC), which is what I use to counsel patients:

  • HSV can be transmitted when lesions are not present.
  • Anyone with a HSV diagnosis is encouraged to inform current and future intimate partners, and to abstain from sex when lesions or their precursor symptoms are present.
  • Correct and consistent use of latex condoms might reduce the risk of transmission.
  • “Daily treatment with valacyclovir 500 mg decreases the rate of HSV-2 transmission in discordant, heterosexual couples in which the source partner has a history of genital HSV-2 infection. Such couples should be encouraged to consider suppressive antiviral therapy as part of a strategy to prevent transmission, in addition to consistent condom use and avoidance of sexual activity during recurrences. Episodic therapy does not reduce the risk for transmission and its use should be discouraged for this purpose among persons whose partners might be at risk for HSV-2 acquisition.”

What that last point means is that ongoing daily treatment with a prescription for an antiviral therapy by the affected partner can be effective protection to reduce the chances of transmission; “episodic therapy,” meaning the antiviral is taken only in cases of an outbreak of lesions, will not provide that protection.

I hope this is clear! You can have intimacy confidently, and I’m glad you’re researching the steps to take!

You say you’re not sexually active, you’re approaching that menopause milestone, and your last pelvic exam was painful. You’re wondering about how to maintain your vaginal health – and wanting to keep your options open should you meet that “special someone.”

Because of the progressive nature of vulvovaginal atrophy in perimenopause and menopause, time is definitely going to work against you – against all of us, for that matter. With with less circulating estrogen, the changes to the genitals will continue to lead to more discomfort and dryness, and over time there is more narrowing and shortening of the vagina.

Vaginal moisturizers

At a minimum, using vaginal moisturizers should be part of your now plan. This may help preserve some of the moisture. Over time, moisturizers tend not to work as well, and then prescription therapies may be necessary to restore integrity and comfort to the tissues.

Using a vibrator or dilators keeps the tissues “in use,” so to speak; that “use it or lose it phenomenon” that we see is definitely a factor for the genitals. I understand that time is a limiting factor. Less time is required for maintenance than for reversing significant atrophic changes, which is to say, the longer you wait to devote the time, the harder it is to restore what is lost. Most women are grateful for having invested the time – especially if they do find themselves in a new relationship.

It is, of course, entirely up to you to decide how to invest your time, money, and energy. As with so many areas of life, the more you commit to focusing attention, the more successful the outcome!

You say you’ve spent some time reading about “the recipe for sexual health,” and are looking for the “how to implement” – and are struggling with HSDD (hypoactive sexual desire disorder). I’m sorry to say that there isn’t a single “how to” or formula for implementing the recipe, because solutions are likely to be as variable as each individual seeking information. The silver lining is that we are, each one of us, wonderfully made!

If your specific issue is centered on low libido, consider that we think of low desire as a biopsychosocial issue: It has to do with bio-hormones and neurotransmitters, psychology (your relationship, your emotional connection, your sexual history, culture, and norms), and social factors (other commitments, stressors, kids, aging parents, fatigue, work issues, and so on).

You can enter “libido” or “desire” in the search bar on MiddlesexMD to find the abundance of discussion on the issue of low libido and understanding desire. I especially like to talk through the Basson model for female sexual response with women who have challenges with desire, because it exposes the complexities of addressing those challenges.


The two products that come to mind are Stronvivo and the Fiera. They’re two entirely different products, but they’ve both been shown in clinical trials to improve desire. Stronvivo is a nutritional supplement for cardiovascular health, while the Fiera is a device designed to increase genital circulation.

And sometimes the answer is further understanding of the condition, and then engaging in mindfulness and intention.

Everyone likes nicely defined muscles, the kind that hint at strength and endurance and a healthy lifestyle. Some of us even work hard to build them. But what if I told you that exercising a certain set of muscles could not only help with the kind of bladder control that eludes many of us older women, but also lead to stronger orgasms and better sex in general? And that those exercises were fairly effortless and could be done anywhere?

You’ve probably already guessed that I’m referring to Kegels.

We’ve talked about these helpful pelvic floor exercises before:

  • Why do them. Strong, toned pelvic floor muscles are tremendously helpful in maintaining bladder control—a particular problem for older women—and in avoiding organ prolapse. Toned pelvic floor muscles also create a firm “vaginal embrace” during sex and can enhance your own orgasm.
  • How to do them. First, identify your pelvic floor muscles. These are the muscles you use to stop the flow of urine. If you’re still not sure where they are, insert a couple fingers in your vagina and tighten so that you feel the vaginal walls constrict. Now, contract and hold for five seconds; release for five seconds. Repeat ten times. Gradually increase until you can contract ten times for ten seconds.  Do these three times a day.
  • How not to do them: You are not tightening your belly, thigh, or butt muscles. Every other muscle should be soft. Do not hold your breath.

Let me just say that however you do Kegels (as long as you’re exercising the right muscles) is just fine. Sit, stand, lie. Make dinner or watch TV. Drive. Got the picture? Kegels are invisible to everyone but you. That’s the beauty of it. However, as with any exercise, Kegels aren’t a magic pill or quick fix. You may not notice improvement for weeks. The important thing is just do it! Regularly.

Let me also say that some women find using Kegel weights (also called yoni balls, ben-wa balls, vaginal cones) helpful in identifying and isolating their pelvic floor muscles. Weights may also help develop those muscles more intensively—like using weights to build your biceps.

With a dearth of solid research on the topic, you will find wild, and wildly diverse, opinions about using vaginal weights. The Kegel Queen swears that doing Kegels can cure everything from organ prolapse to bad sex. She would never consider using vaginal weights to augment them. On the other hand, Kim Anami, the Kung Fu Queen of vaginal weightlifting, says that most women aren’t helped by Kegels because they don’t do them properly. She, however, will teach you to move furniture, shoot ping pong balls, and lift weights with your vagina. Or control your partner’s ejaculation. This might terrify most men. Or not.

I’m thinking that the truth probably lies somewhere in between.

Luna Beads Vaginal WeightsWhile they’re not for every woman, vaginal weights add a level of gravitas to your commitment to Kegel. They come in a rainbow of sizes, shapes, and materials, from jade to silicone, balls to barbells. We’ve culled the selection to a manageable assortment in our shop. You can choose from a simple, inexpensive “starter” kit with two silicone balls to a programmable Elvie trainer that syncs with a phone or tablet app to customize your Kegel workout and give you biofeedback to make sure you’re doing them correctly. Then there are the classic Luna Beads, which are beautifully designed and easy to use.

To use Kegel balls:

  • Start with the lightest weight. Lubricate it well. (Don’t use a silicone lube with silicone balls.) Insert one just beyond your pelvic floor muscles, as you would a tampon.
  • While sitting, perform ten sets of Kegels—contracting, holding, and relaxing for five seconds each.
  • The next level is to practice standing with the weights in place. You have to maintain the contraction to keep them from falling out. Try to extend the length of time you can hold the balls.
  • If you’ve mastered standing, you can try holding the Kegel balls while squatting and then while walking around doing normal tasks. This level may be beyond most of us estrogen-depleted, “mature” gals.
  • Wash with soap and warm water. Dry and put away.

Kegels of any sort, weighted or not, are an important part of your downtown health regimen. They can help with bladder and bowel control; they can help keep your organs where they belong. Kegels improve muscle tone and blood flow to the pelvic floor, which makes sex more pleasurable for you and your partner. And if you decide to practice a little vaginal weightlifting, you can go here for inspiration.

You say you’re using estrogen therapy, have sufficient lubrication, but are experiencing pelvic muscle spasms that cause you some discomfort during sex. You’re wondering whether being sedentary contributes to the problem, and whether a vibrator, which your doctor recommended, may help.

VibratorsIt’s unlikely that sitting too much would contribute to the muscle spasms (although as a doc, I need to recommend more physical activity). Unfortunately, most of the time we don’t have a good explanation as to the cause of muscle spasms. A vibrator works by increasing (through stimulation) blood supply to surrounding tissues, which, in turn, promotes vaginal health. If you choose a vibrator, make sure it’s one you can use internally, not just externally on the clitoris.

The other tool that’s often helpful with muscle spasms is a set of vaginal dilators. These are designed to provide a gentle stretch to pelvic floor muscles to reduce spasm.

I hope this is helpful! Part of the solution is to be confident you can address the issue.

If you’re wearing a Fitbit to bed, like a patient I saw last week, you might be seeing pretty colored charts that confirm just exactly how poorly you slept last night. And if you’re like her, it may only be increasing your stress about what you already know: You’re tired! You’d like to sleep through the night!

Yes, as you’re likely tired of hearing, it’s hormones. Estrogen and progesterone are in decline, and the mix of hormones (add cortisol, the “stress hormone” to the cocktail, too) may be less friendly to sleep than it once was. Hot flashes, which can happen day or night, come with a surge of adrenaline, from which you need to recover before you can settle back to sleep.

What you're thinking of in the middle of the night is spam. Delete it!A few of the people I’ve talked to for The Fullness of Midlife, our podcast, have had some light to shed on our sleeplessness. Joan Vernikos, a retired NASA health science researcher, says sleep is “like a cleaning service in an office. …The cleaning service starts out by emptying the garbage cans, by tidying up, picking up—and that’s what happens with the brain during sleep in the various cycles. If you wake up and you don’t sleep well, not only are you going to make mistakes the next day, but you’re not going to detox your brain.”

Menopause can sometimes bring its own befuddlement, right? Memory lapses. Foggy thinking. Well, add in some sleep deprivation and a brain in desperate need of a “detox,” and you can imagine a day that you’d rather forget.

Another podcast guest, Dr. Pamela Peeke, gave us a pep talk about making “sleep hygiene” a priority. She points out the relationship between sleep and diet: We’re much better able to be in control of our appetite—not because we lack self-discipline but because of busy hormones at work in our bodies—when we’re well-rested.

Make “sleep hygiene” a priority? Well, it sounds good. And there’s plenty of reason to do it, from easier healthy eating to clear-headed days. Here’s what it takes:

  • Make your bedroom comfortable for sleep. Is it dark enough? Cool enough? You might want to layer your bedding like you layer your outerwear for a hike on an early spring day—so both you and your partner can be comfortable throughout the night. Consider white noise if sounds are keeping you awake. If now is not the time to invest in your good sleep, when is?
  • Exercise. To patients in my office, I recommend 45 minutes five days a week of real exercise—walking, swimming, biking. Something that gets the heart-rate up. If some part of that can be outdoors, even better, because natural light helps us with our sleep-wake cycles. Get it in early, so you can avoid exercise in the three hours just before bedtime.
  • Stay awake during the day. I know it’s tempting to nap when you’re not sleeping well at night. But napping for more than 20 to 30 minutes can make it more difficult to sleep deeply overnight, which is when that brain detoxing Joan talked about happens.
  • Ease away from stimulants and heavy foods. The effect of caffeine can change as our bodies change. And the relaxing effect of alcohol wakes us up later when we’re metabolizing it. Digesting heavy foods can do the same.
  • De-stress generally, but especially as part of a pre-bed routine. Excess stress is a health challenge for us at any age. While it’s unlikely you can eliminate stress from your life, you can at least develop some routines for putting it in its place before you turn in for the night. Set a routine—yoga for relaxation, reading a novel, writing in a gratitude journal, taking a hot bath—that signals that it’s time to settle down. Avoid screens in the hour before bed, especially contentious text or Facebook exchanges or upsetting documentaries. And remember what Joan said when you’re churning at night: “What you’re thinking of in the middle of the night is spam. Delete it! You can’t do anything about it.”

A perhaps unexpected side effect? Since stress and fatigue are two of the three most common obstacles to sex (the third is lack of privacy), you just might find yourself with a little more romance in your life.

Makes “sleep hygiene” sound a little sexy.

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