Archive for February, 2012

When “intimate massagers” are placed between the flannel pajamas and the birdhouses in the Vermont Country Store catalog you know that vibrators have gone mainstream! The ad rightly points out that sometimes, as we age, we need a little more help getting where we used to go effortlessly.

As I’ve said before, regular stimulation helps keeps our sexual organs responsive and functional, and the stimulation might have to be stronger and longer. That’s where a vibrator comes in handy. The steady stimulation it provides tones the muscles and reinforces the nerve and vascular pathways to your genitals. But using a vibrator can also help you learn where you’re sensitive and how you respond to different stimuli (which will improve your lovemaking). It can get you aroused during foreplay, and it can be a gentle way to “cool down” afterward.

A vibrator is an equal-opportunity toy, and it can be a useful aid for couples as well. In this post, we’ll discuss some features to consider before buying a vibrator, and we’ll offer some suggestions for your first session or two.

Generally you want your first vibrator to be a versatile, multi-function machine until you know more specifically what you like. Perhaps choose a wand-style vibrator that can stimulate you internally and externally. (Some do both at the same time.) Typically, models with a  good rechargeable battery last longer and deliver stronger vibrations than those with disposable batteries—but there are some nice exceptions; check for motor strength. Opt for a vibrator with variable speeds so you can change the level of stimulation.

Some women use a vibrator in the bathtub, so you might consider a waterproof model. If noise is an issue, that might factor into your decision. You also have a choice of materials, from stainless steel and hard plastic to soft, fleshlike silicone. Some users recommend starting with a hard plastic model that doesn’t mute the vibrations and is easy to clean. If you want a less direct sensation, you can cover it with a towel or hand cloth.

Don’t spend a lot on your first vibrator until you know what you like. Better to be out $40 than to spring for $80 and find out you don’t like vibration at all. (Some women don’t.) After a few practice sessions, you might end up ordering several vibrators for different uses—small, discreet numbers for travel, say, or multipurpose gadgets for vaginal and clitoral stimulation.

Once you’ve received your first vibrator, however, take some time to get acquainted. Remember that part of the object is to learn about your own body—what stimulates you, where the sweet spots are, how you like to be touched.

Set aside a few hours of undisturbed time when you can relax. You might want to start in the tub. You can set the mood with music, a glass of wine, dim light, scent, even candles. You could read a sexy story or watch a movie that turns you on. Begin exploring your erogenous areas gently with your hand—labia, clitoris, nipples, vagina, thighs, belly, noticing the various sensations and what spots are more sensitive.

Lubricate your hands, genital areas, and the vibrator. (Don’t use silicone lubricant on a silicone vibrator, however). Turn it on and feel the sensation with your hand. If you have variable speeds, start with the lowest one. Place the vibrator on your thighs. Try your nipples if you like stimulation there. Place it on your perineum (the space between your vagina and anal opening). Move on to your labia; place it on your clitoris.

Try various speeds. Let youself become aroused, then back off. Your orgasm will be more powerful if you let the arousal build. Can you orgasm clitorally? Can you orgasm more than once? Do you need more stimulation or a higher speed?

Maybe that’s enough for one session. Or maybe you want to move on to the vagina. Insert the vibrator (assuming you have a wand-style model) and move it around. Try different speeds. Can you find your G-spot? Try clitoral and vaginal stimulation simultaneously. (Use your hand and the vibrator.)

For many women, the clitoris, labia, and first few inches of the vaginal opening (the vestibulum) are the most sensitive.

Use your vibrator to stay “in shape” between lovemaking sessions or to “warm up” beforehand. But let’s not neglect the new possibilities a vibrator brings to couples’ sex as well.

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HPV is an unlikely cause for pain with or after intercourse. It’s associated with abnormal pap tests, which may require further investigation—like the biopsy you say you had. Much less commonly, it can cause genital warts. If the warts happen to be at the opening of the vagina, they can become irritated and cause discomfort, but that’s really very rare.

It’s more likely the discomfort is related to the atrophic changes of menopause, which you may not have been aware of between relationships. In the absence of estrogen, the tissues become thin and less distensible—meaning less stretchy and able to expand—and also more fragile and easily injured. This can happen even if you don’t perceive dryness.

You didn’t say how long you’ve been sexually active; this problem may resolve itself: It’s the opposite of “use it or lose it”! But because menopausal tissues don’t rejuvenate quite as well as younger, fully estrogenized tissues do, you might consider using a moisturizer or localized estrogen. But I wouldn’t worry about HPV being a cause.

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Remember the G-spot brouhaha?

Yes, there is one. No, there isn’t. Is. Isn’t.

If you were aware of that controversy you might wonder whatever happened to it. Was anything about the mysterious G-spot ever resolved?

For all intents and purposes, after a flurry of attention in the 1980s, the G-spot seemed to go underground for a decade or two, but lately, with the advent of newfangled imaging devices, the search for the G-spot has resurrected once again. So, in case you’ve been wondering, let us bring you up to date on this mysterious region.

The G-spot is defined (and yes, there is a definition) as an erogenous area about the size of a nickel located 2 to 3 inches inside the front wall of a woman’s vagina.

The name comes from the German gynecologist Ernst Gräfenberg, who first wrote about its existence in 1950. But a mysterious pleasure center in roughly the same place had also been mentioned in ancient Indian texts and by Regnier de Graaf, a Dutch physician, in 1672, who wrote that secretions from this area “lubricate their sexual parts in agreeable fashion during coitus.”

But it was the publication of The G-Spot and Other Discoveries about Human Sexuality in the 1980s that ignited a frenzy. Couples contorted themselves into pretzels seeking the elusive mind-blowing orgasms that accompanied just the right stimulation. (Leaving many women feeling inadequate and their partners frustrated, I’m sure.) Researchers, too, overheated their Bunsen burners trying to find the darned thing.

Then, without further fuel to fan the fire, the short attention span of popular culture wandered, and interest in the G-spot waned.

In 2008, however, Italian researchers using new ultrasound technology discovered a thickened area on the front vaginal wall of about half of 20 women. Women with this thickened tissue were more likely to experience vaginal orgasms. In 2010, a group of British researchers asked 90 pairs of twins if they had a “so called G-spot, a small area the size of a 20p coin on the front wall of your vagina that is sensitive to deep pressure?”

Unsurprisingly, given the subjective nature of that question, the results from the British study were ambiguous and were challenged by other scientists. The following month French researchers, askance at the sloppy work from the boys across the channel, declared that 56 percent of women did indeed have “un point G.”

Physiologically, a G-spot has not been definitively identified by gynecologists, nor in dissections nor consistently in ultrasounds. So the mystery remains, according to urologist Dr. Amichai Kilchevsky, who led an extensive review of all research on the issue. “Without a doubt, a discreet anatomic entity call the G-spot does not exist,” says Dr. Kilchevsky.

Yet, women consistently report that stimulating the front of the vaginal wall produces a deep, pleasurable orgasm. “…it has been pretty widely accepted that many women find it pleasurable, if not orgasmic, to be stimulated on the front wall of the vagina,” said Debby Herbenick, researcher at Indiana University and author of Because It Feels Good.

According to Australian researcher Dr. Helen O’Connell, the clitoris, urethra, and vagina all work together during sexual stimulation, creating a “clitoral complex.” Since the urethra lies along the outside of the vagina and the clitoris has deep “roots” within the vaginal walls it’s no stretch to imagine that all the parts work together during sex.

Some doctors compare the G-spot controversy to obsession over penis size—much ado about nothing. Lots of women don’t orgasm with vaginal penetration alone; indeed, most of us need both vaginal and clitoral stimulation to orgasm. So, if “we don’t even have orgasm all figured out yet, I don’t know why we would expect to have the G-spot figured out,” Herbenick said in an article on Netdoctor.

Because of its approximate location, the G-spot is devilishly hard to reach, especially in the standard missionary position. However, if you’d like to spice up your bedtime routine with a little research of your own, try sitting astride your partner, on a sturdy chair or firm surface. Lean backward so the penis has a better chance of connecting with the front of the vagina.

If this sounds too acrobatic for a fun Friday night, you can always fall back on the trusty index finger. Lie on your back while your partner inserts his finger, using a “come hither” motion to stimulate front of the vagina. Or try a toy. Special G-spot vibrators are available that are longer with a kink at the end. Results are still mixed, so focus on the exploration, not a specific result.

And remember to be well-lubricated and relaxed. Light a few candles and some incense. Research has never been so fun.

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I’ve talked before about dyspareunia, or pain with sexual intercourse. It’s a common problem; up to half of us are affected at least once during our lifetimes. This issue is a special focus for one of the MiddlesexMD medical advisors, Dr. Susan Kellogg Spadt, so I asked her to share her expertise.

The most common type of dyspareunia is referred to penetrative or superficial dyspareunia, meaning that it occurs at the opening of the vagina rather than deeper in the pelvis. Penetrative dyspareunia can be further classified as situational, secondary, or primary.

Situational penetrative pain may be related to transient factors like inadequate lubrication, certain thrusting techniques, a vaginal infection, or vulvar irritation. Secondary dyspareunia refers to the onset of consistent penetrative pain associated with each act of intercourse after a history of pain-free intercourse. Primary dyspareunia refers to the onset of penetrative pain at first intercourse, followed by consistent pain with each attempted act of intercourse.

Secondary and primary dyspareunia may be associated with a myriad of causative factors, including lack of estrogen in the vulvar tissues, vulvar dermatoses, scarring, fissures or adhesions, and psychogenic issues like past or current sexual abuse. One of the most common causes of pain is vulvar vestibulitis syndrome (VVS), also referred to as provoked vestibulodynia (PVD). This is characterized by localized redness, generalized rawness, itching, discomfort at the vaginal opening, and discomfort associated with a gentle cotton swab touch, upon exam, to the glands at the vaginal opening.

Definitive causes of VVS/PVD have not been identified. Events preceding symptom onset may include mechanical trauma caused by friction against atrophic tissues (tissues without sufficient estrogen, as happens after menopause) as well as irritation after vaginal infections, bladder infections, viral exposure, antibiotic use, or localized allergic responses.

Healthcare for the woman with VVS/PVD begins with competent and early diagnosis. Up to half of women are misdiagnosed. Most women are told that their symptoms are psychological, and that they need to “relax” or that they have an ongoing yeast infection. A simple physical examination can usually provide the correct diagnosis. In the “touch test,” vulvar structures like the glands of the vulva are tested with a cotton swab; the woman with sexual pain will often find these touches painful. Touch testing should be performed as part of a thorough pelvic and vaginal examination, including cultures for species identification for yeast (and bacteria, if necessary).

Managing dyspareunia often begins with anti-irritant hygiene regimens: avoiding scents, allergans, and irritants from soaps and other products. Other treatments a healthcare provider may prescribe include topical hormone creams, antifungal therapy, pelvic muscle physical therapy, biofeedback, and/or surgery.

Alternative approaches include use of topical creams like Neogyn vulvar soothing cream, compounded creams containing capsaicin, amitriptyline, cromolyn, atropine, and other therapies such as acupuncture.

Women should be aware that symptoms are not “in their heads,” and that it may take months for pain to diminish. Patience is paramount. Maintaining a physical relationship (other than intercourse) with a partner is important, because “complete intimacy avoidance” can be common among women with sexual pain and can be detrimental to the couple’s relationship.

relationship therapist can help women—and their partners—coping with sexual problems. Both patients and clinicians can learn more about the condition by visiting the National Vulvodynia Association website at www.nva.org

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When Things Go POP

In a post last week I talked about the very important pelvic floor muscles—that springy base that supports our pelvic organs and controls the orifices that pass through it. While it’s pretty darned important to keep our pelvic floor toned and in good working order, that becomes harder to do as we age and absorb more of the slings and arrows of outrageous fortune. Or just of daily life.

One common side effect of aging on those muscles is pelvic organ prolapse—or POP. This is when one or more of the organs resting on our pelvic floor—the uterus, the bladder, and the bowel—sag into one another, sometimes causing the vagina to protrude. It’s like pebbles on an elastic surface. If the surface is taut, the pebbles stay in place; relax the surface, and the pebbles all roll toward the center.

When we were young, our pelvic floor muscles were taut and nicely toned, and our organs were all held in place by ligaments and the pelvic floor. Over time, those ligaments stretch and sometimes tear. The pelvic floor sags and loses tone, and the organs tend to drop, move around, and squish together.

Factors that cause or exacerbate POP are

  • vaginal delivery, especially of large babies
  • heavy lifting
  • chronic constipation
  • chronic cough
  • being overweight
  • menopause and loss of estrogen

Since virtually all of us have encountered (or will encounter) at least one of those conditions, pelvic organ prolapse is, as you might expect, extremely common. About half of us will experience some degree of prolapse in our lifetime. Not only that, it’s been around for a while, too; it was mentioned in literature as long ago as 2000 B.C.!

Often, the condition is mild and you may not even know you have a prolapse, in which case you don’t need to do anything. On the other hand, you may experience one or more of the following unpleasant symptoms:

  • difficulty urinating or having a bowel movement
  • leaking urine with any “bearing down” motion, such as running, sneezing, or coughing
  • a sudden urge to urinate and not quite making it to the bathroom
  • leaking small amounts of stool
  • frequent urinary tract infections
  • feeling as though something is falling out of the vagina
  • tissue emerging from the vagina
  • partner’s sensing “something is in the way”; more rarely, painful intercourse

Our organs can prolapse in several creative ways. The bladder can fall into the vaginal wall in front, which is called a cystocele. The bowel can tip into the vaginal wall behind, called a rectocele. Or, the uterus can fall down into the vagina, often squishing it out the vaginal introitus (entry).

Treatment options include lifestyle change, surgery, or using a pessary. Lifestyle changes can prevent further damage to the pelvic floor:

  • Maintain a healthy weight to relieve pressure on the pelvic floor
  • Don’t smoke, which is often associated with a chronic cough
  • Avoid heavy lifting
  • Avoid constipation and straining with bowel movements
  • Do kegels. (Lots of kegels.)

Pessaries are simple silicone devices that are individually fitted and inserted into the vagina to hold it in place. They need to be removed and cleaned every few months, which can be done at home or in a doctor’s office. They’re usually effective, but they can limit the depth of penetration during sex.

Additionally, topical estrogen can help improve tone in the pelvic floor muscles and vaginal walls.

As a last resort, various surgical options can relieve the discomfort and distressing symptoms of prolapse. Sometimes this involves a hysterectomy and/or reconnecting the torn ligaments. Sometimes a synthetic mesh material is used to support the prolapsed organs.

Consider the surgical option carefully, however. According to the National Association for Continence (NAFC), about 11 percent of women have surgery for pelvic organ prolapse, and about 30 percent of those surgeries fail, necessitating yet another surgery. These failure rates have led some experts to consider POP a “chronic” condition. Additionally, a recent notification from the FDA warns against using the surgical mesh because of a high incidence of “serious complications.” Also, it may be impossible to remove the mesh once it’s in place.

Pelvic organ prolapse is common; it can cause embarrassing or annoying symptoms. It can interfere with sex, and it can even interfere with everyday activities. Once a prolapse has become severe, kegel exercises are less effective and treatment options are less reliable.

The best approach is to take care of your pelvic floor before things get out of hand. So, as we said before… start kegeling.

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An advisory board discussion turned to our experiences as professionals supporting women who find themselves newly single, often after a divorce. I asked Mary Jo Rapini, one of our medical advisors, to share some of her observations and advice.

A divorce leaves most people confused, hurt, and angry. Sex with another person—or sex at all—may be the farthest thing from your mind in the midst of a divorce. Sex with an ex is more common than you might think, but it usually doesn’t last; it may help put closure on the end of the marriage. Sex with an ex usually reminds you why you split and reinforces that you are alone (one of the loneliest feelings is waking up after your ex leaves from a night that was nothing more than sex).

Be aware—both if you compare yourself to your partner and as you meet new people—that men usually have more partners after a divorce. Men suffer more from being alone. Their heart rate and respiration take longer to return to normal after an argument, and they have less of a social network to turn to for emotional support. Many times their attempts to find someone new quickly are driven by emotion as well as sex. Women have stronger social networks that help to emotionally support them. This is a benefit for women and also prevents them from feeling the “need” to begin dating right after a divorce.

For both women and men, there are new sexual adventures waiting after a divorce. On-line dating, texting, sexting, emailing, and social networks have all provided a virtual world of new suitors. If you have been married for a long while, this may seem overwhelming and intimidating. It may be one of the reasons you hesitate to get back into dating. I hear questions like these from many recent divorcees; “How do I date?” “Where do I begin?” “What do men or women expect now while dating?”

Before you begin dating, get comfortable with both your post-divorce body and your thoughts about sexuality. If you were married for a long time, sex may have become routine, and your body most likely was accepted for the way it was. If you don’t like your body, this is an optimal time to begin a healthier life style that includes taking time for yourself. Exploration of your own sexuality can be a part of that healthier life style. Rushing into dating before you know what makes you feel good, where you like to be touched, and how to touch you won’t be as successful as taking your time and knowing yourself. You aren’t the same person you were when you got married. Your body isn’t the same body, either. Here are some things you can do to understand your sexual self post divorce:

  1. Take at least one evening or morning a week to begin touching yourself. Sitting in a bath tub with nice music, bubbles, and a hot tea or other favorite beverage is a wonderful opportunity to touch your skin and notice where your body is most sensitive. If you feel numb since the divorce, watch for goose bumps. These are good indicators of areas on your body that enjoy touch.
  2. As you feel more comfortable with your own touch, introduce a vibrator. If you aren’t sure of which kind to try, begin with a vibrator you can take in the water. The water is relaxing and if you are still uncomfortable looking at all your body parts (many women and men have body image issues after a divorce) the water is a gentle way to cover parts you don’t like. Massage your neck, arms, breasts, chest, groin, thighs, and then gently introduce it to the genitals.
  3. When you are finished in the bath, gently dry yourself and begin looking in the mirror. Note the areas of your body that are sensitive to touch and appreciate those. Repeating a mantra or a favorite quote or prayer at this time is a loving addition to your body and will begin helping you feel more sexual and confident.
  4. After dressing, sit down and write down things that you appreciate about your body and list reasons someone would want to love you. Keep these writings in a journal where you can continue this practice. Writing will begin your healing process of self love, discovering your sexual self, and preparation to love again.

Whether you wanted the divorce or were forced into one, knowing your intimate, sexual self post-divorce is so important. The majority of divorcees do go on to have relationships and marriages. Many of these don’t work out, and it’s often because one or both partners rushed into another relationship without fully appreciating what they had to offer another.

If you didn’t want the divorce, it’s especially important to heal emotionally, as well as restoring your sexuality. These suggestions will help you get through the immediate months following a divorce:

  1. Talk to a counselor to help you navigate your feelings. Venting to your friends, parents, and children is not helpful and can actually isolate you. Children can be emotionally damaged when parents trash-talk an ex, so confide in a counselor and one or two close friends.
  2. Make exercise a part of your daily life. Exercise helps motivate you when you feel too fatigued to go on, and it restores your body image. If you can’t exercise by yourself, ask a good friend to walk, run, or go to the gym with you.
  3. Join at least one support group or a like-minded group. This will help you minimize your aloneness; it will also get you out into the community where—who knows?—you may meet new people, including, perhaps, someone you’d like to date.
  4. Minimize meeting up with your ex as much as possible. The more you engage with your ex, the more difficult moving on can be.
  5. Continue to enjoy the events you used to. You may not “feel” the same enjoyment at the same deep level, but eventually you will.

Going on with a new life you never wanted or chose is painful. Many times, the partner left feels revengeful, and although this is a common feeling (don’t beat yourself up for feeling it), you eventually have to give that up, too. Before you give up on that feeling though, remember: The best revenge is becoming the best version of you! This includes taking care of your emotional and spiritual health, your children’s health, and your physical health. You will make it, even though your heart may be breaking. You are strong, you will survive, and you will continue to grow, change, and love again.

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*Luv* Your Pelvic Floor

The pelvic floor may be the most neglected and underrated part of our anatomy—on the level of the pinkie toe or the back of the knee. But for sheer impact on our quality of life, we neglect the pelvic floor to our peril. Those muscles play a critical role in everyday function, like bladder and bowel control, orgasm, and keeping our organs where they belong.

Ergo, not a good idea to neglect the pelvic floor.

Maybe you noticed that you had less urinary control after the birth of a child. Maybe you noticed a slackening of the “vaginal embrace” during sex. Maybe lately you’re even feeling like you’re sitting on a stone “down there” or have a little bulging protrusion in your vagina. Maybe you have to urinate more often or you get more urinary tract infections. Maybe sex is more painful.

Did I mention it’s not a good idea to neglect the pelvic floor muscles?

The pelvic floor is like a sling that runs from our pubic bone in front to our tailbone in back and to our hip bones on either side. (Or—as one doctor put it: once, it was like a trampoline; now, it’s like a hammock.) It performs a fancy figure eight around the vagina, urethra, and anus, controlling, supporting, and maintaining good function in those unsung and important areas.

But it’s also a deep muscle that works in tandem with other muscles in the back and abdomen. And all these muscles have to be balanced and working harmoniously for us to be pain-free and without uncomfortable symptoms, such as that bulge that signals a uterine prolapse or that tendency to “laugh and leak.”

This is because the pelvic floor is subjected to unique demands compared to other body parts. It literally holds our organs in place, so pressure from childbirth, obesity, trauma, heavy lifting, even hard coughing, and, of course, simply getting older, can weaken the muscle and cause things to sag over time.

Further, as we lose estrogen during menopause, this muscle tends to lose tone. And since the pelvic floor surrounds the vagina, its ability to help out with orgasm and that nice, firm vaginal embrace is compromised, too. Darn it.

The crazy thing is that about half of women will experience some level of incontinence or prolapse in the course of a lifetime often without saying a word, sometimes for decades. Surgical procedures, in addition to carrying all the risks of major surgeries, are controversial and without good long-term outcomes. One-third of women who have had surgery for incontinence return for a second surgery.

Now, you could have surgery to fix incontinence or prolapse. But why not start with a safe, simple approach? Like maintaining a healthy weight. Like not smoking. Like exercise.

Like kegels. (You knew I was going there.)

Regularly exercising and toning your pelvic floor with kegel exercises is cheap, noninvasive, and incredibly effective in reversing the symptoms of incontinence and prolapse. Plus, a well-toned pelvic floor will have better blood flow and nerve pathways, which amounts to more sensation, stronger orgasm, and a nice, firm vaginal embrace.

The tricky part is to exercise the right muscles. You shouldn’t be tightening the abdomen or the buttocks. You shouldn’t be holding your breath. Our website has a little primer for correctly doing kegels. Kegel exercise tools, such as vaginal weights, may also help because you have to exercise the right muscles to hold them in place.

There are even some smart-phone apps to help you with the regimen. (You know it’s gone mainstream when there’s an app.)

First, discuss your symptoms with your doctor to make sure there aren’t any complicating issues involved. And then… start kegeling!

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