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You asked. Dr. Barb answered.Intrarosa is a new product for treating vaginal atrophy, approved by the FDA in November of 2016. It will be available by prescription only; it’s not yet in pharmacies but is likely to be later in 2017. The clinical trials for Intrarosa are favorable for treating vaginal atrophy, or genitourinary syndrome of menopause causing painful intercourse. It is an adrenal hormone, prasterone (dehydroepiandrosterone), formulated as a once-a-day vaginal insert.

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.

You asked. Dr. Barb answered.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.

“Midlife: when the Universe grabs your shoulders and tells you “I’m not f-ing around, use the gifts you were given.” —Brene Brown

I don’t know about you, but I love seeing old people in love. The way they hold hands toddling down the street. The way they go about their daily tasks having made peace with the past. I think it’s a miracle when love lasts this long and ages this gracefully.

Relationships encounter lots of challenges in the course of a lifetime, but from my own observations, which are supported by the data, the midlife transition, that somewhat fraught passage, is nothing to sneeze at. Menopause aside, the awareness of time passing often arrives unexpectedly and with surprising intensity, leading both men and women to make decisions that belie common sense, compared to which the red Corvette might be among the most benign. For example, the highest divorce rates from 1990 to 2010 occurred among couples over 50, according to this study. Concurrently, co-habitation rates among over-50s tripled from 2000 to 2013.

Whatever the cause—longer lifespan, greater economic freedom for women especially, cultural change—the fact is that something shifts when folks approach that midlife marker, and it’s often the woman who agitates for change.

This isn’t necessarily a bad thing. Periodic reevaluation and readjustment is healthy. So is honestly confronting ingrained habits and responses that ultimately stifle intimacy and deflect communication. Like a vintage car, most lengthy relationships require a major or minor tune-up now and then.

Still, midlife often opens a Pandora’s box of restlessness and dissatisfaction—the perennial is this all there is? What happened to the passion? Am I missing out? Do I really have to endure the quirks and habits of this individual for the rest of my life? What is really important? What dreams have I buried?

Those existential questions herald an important crossroad—the frontier between youth and maturity. With regard to your most intimate relationship, you can:

  1. Invest in what you have. Work on ways to reinvigorate and reignite the flame. This won’t be the passion of your youth, but something burnished by time and familiarity. A golden glow rather than red-hot embers. If your relationship is solid and things have just cooled off with time and neglect, it’s worth investing for the future.
  2. Reinvent it. Sometimes a creative change eases the chronic irritations that can erode a longterm relationship. Some couples successfully stay together but give themselves extra space with separate households, for example, or planned time apart, or splitting the daily finances and decision-making that cause problems. Rejiggering the quotidian foundation might ease the annoyances enough to allow a couple to value and appreciate the familiarity and intimacy that has developed over many years.
  3. Scrap it. This is a very tough judgment call, but some relationships have never worked well; some matches are misses; and sacrificing the years you have left may not be worth it for one or both of you. Dismantling a lifetime is a heartbreaker (or—maybe a release), but you may end up in a better place when the dust settles.

Major life transitions should never be done in haste. They deserve a considerable degree of mature reflection. We all know people who make fast and sometimes rash decisions in the throes of passion or as a desperate attempt to seize a day that appears to be slipping away. Amid the landmines of midlife, the baby is sometimes thrown out with the bathwater.

Here’s a little reality check.

However irresistible the urge, don’t blow up your life. Wait. Reflect. Seek counsel. The demand to create something more authentic, to realize cherished dreams is real and should be honored. But the best path forward probably isn’t over the shattered pieces of your present life.

You still have time. You can still seek your bliss, optimize potential, maybe with more freedom and effectiveness now that the kids are grown and you’re more self-confident. Start a business. Learn Chinese. Travel. The world is your oyster—just in a different shell than when you were younger.

Romantic passion is a landmine. Passion is powerful, blinding, and temporary. You can’t make good decisions in its throes. And even the most incredibly passionate relationship will inevitably fade with the demands of daily life. White-hot passion doesn’t last; it’s not meant to. And when reality checks in, the dirty socks on the floor look the same. Trust me on this one.

Talk to someone if you need to. A therapist. A friend. You can’t see things clearly (even if you think you can). Trust the counsel of someone wise and objective.

Don’t freeze out your partner. However restless and unsettled you may feel, your partner is probably not the enemy. You want to elicit support, not resistance. Anyone would feel threatened when cracks appear in the foundation of a secure life. Anyone would feel uncomprehending and maybe hurt. If, however, you are able to communicate what you’re feeling, even if it’s confused and incoherent, at least there’s a bridge rather than a canyon.

“This too shall pass,” writes blogger Deb Blum in this article. “It will pass more gracefully and completely if everyone is gentle and loving and gives the space necessary to get through this time.”

And that study about over-50 divorce rate also found that the longer a marriage lasts, the less likely it is to end in divorce. So those old folks holding hands in the park? The real deal.

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.

Strengthen your floor!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!)

 

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

You asked. Dr. Barb answered.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.

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.

You asked. Dr. Barb answered.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!)

And there’s one more newer product, the Fiera arouser, that’s been very helpful for many women with arousal (and orgasm). It’s promoted as helpful for “before play,” increasing circulation and lubrication.

I hope some combination of these suggestions solves your mystery!

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.

You asked. Dr. Barb answered.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.

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