Archive for February, 2013

Maybe you’re divorced or widowed. Maybe you’ve been single and partnerless for a while. Maybe you found someone after a long dry spell. Or, maybe sex has just been darned painful lately.

Time was, you could count on your vagina to do its job. It just worked. You didn’t have to think about it. But with loss of estrogen you’ve been experiencing lately, that uncomplaining organ begins to act up. And if you haven’t used it lately, it actually begins to shrink and shorten.

Now, if you’ve been on the sidelines, sexually speaking, for a while, you won’t be able to jump back into the game without some preparation. At this point, sex can be surprising, and not in a good way.

After menopause, the name of the game is “use it or lose it.” Furthermore, it’s a lot easier to maintain vaginal health than to play catch-up after ignoring the situation downtown for a while.

As we explain in detail in our recipe for sexual health, when you lose estrogen, the vaginal walls become thin, dry, and fragile. They atrophy. Without regular stimulation, the vagina can become shorter and smaller. It can also begin to form adhesions and stick together. Some cancer treatments exacerbate this process.

We’ve talked about moisturizers, practicing your kegels, using a vibrator or other form of self-pleasuring as part of your sexual health maintenance program.

But another important tool, especially if you’re currently without a partner (or are trying to rehabilitate now that you’ve found someone) is the regular use of dilators.

Say what?

Dilators are sets of tubes, usually made of high-quality, cleanable plastic, that start small (half-inch) and gradually larger (up to an inch and a half). They’re inserted into the vagina in gradually increasing sizes to stretch the vaginal walls, making them open enough (which is called patency) and capacious enough to do their job.

It isn’t quick, but it is effective.

Occasionally, I run across suggestions for homemade dilators that make use of various round objects. Don’t try this. It’s important for all kinds of reasons to use only high-quality dilators that are smooth and easy to hold, that increase in size gradually and consistently, and that can be cleaned well.

You should only use the safest, highest quality product in this important place. If you don’t know where to look, we offer a selection of dilators on our website that we’ve carefully vetted. These will work much better for you than those candles you were eyeing.

Here’s how you use them:

Relax. Take a bath—it makes all those tissues soft and pliable. Lie comfortably on your back with your knees open.

Lubricate the smallest dilator well with a vaginal lubricant.

Gently insert it into the vagina. Keep all those pelvic floor muscles relaxed. Breathe. Push the dilator in as far as you comfortably can.

Hold it there for 20 to 30 minutes. Do this twice a day.

When you can comfortably insert the smallest dilator, graduate to the next largest size.

It can take three months or more to restore vaginal capacity.  Once you’re comfortable with the largest dilator, continue the regimen at least once a week if you aren’t having sex regularly. And don’t forget the moisturizers.

It takes patience and diligence to rehab your bottom, but you can do it. With a little TLC, everything will work as well as it ever did and sex can be every bit as luscious as it ever was.

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More from the Trenches

In a previous post Dr. Susan Kellogg Spadt, a MiddlesexMD medical advisor, described some of the impediments to sexuality that she sees affecting women as they age. The list, which began with internalized ageism, sexual scripts from our families of origin, and low self-esteem, continues in this post…

Performance anxiety. Men aren’t the only ones who worry about “performing.” All those physical changes to our sexual apparatus that are discussed on MiddlesexMDvaginal dryness, pain, reduced sensation, lack of interest—can contribute to performance anxiety for women, too.

As one 52-year-old woman said, “I can no longer tell how my body is going to behave. It makes me nervous in bed.” As with men, this inability to trust or predict how your body will respond can affect your ability to enjoy or your desire to have sex. Some women (and some men) just decide not to be sexual anymore.

Women need to know that there is help for these physical changes—again, all the things discussed on the blog and the website—such as moisturizers, lubricants, vibrators, and dilators. These tools can help us remain comfortable and familiar with our changing bodies, so that we’re less anxious when we’re with our partner.

Depression. Older women get depressed at somewhat higher rates than younger women. That’s what the research says. Not only that, but the side effects of some antidepressants include decreased desire, vaginal dryness, and delayed orgasm.

So what’s a woman to do?

Talk to your healthcare provider. You need counseling for the depression, and if medications are affecting your libido, discuss alternatives with your provider. It’s not easy, but you could end up feeling better and enjoying sex again.

Lack of attraction to partner. Yes, I hear this from women—the spark is gone. They just aren’t attracted to their partner anymore.

Maybe the relationship was always difficult or lacked physical intimacy, and the couple stayed together for practical reasons. Or maybe physical changes due to the partner’s aging or illness have affected the woman’s physical attraction. According to the literature, this happens in both women’s heterosexual and lesbian relationships.

Fantasy is one way to mitigate the “turnoff.” Use your imagination to turn the frog into a prince. Sex therapy may be another aid to establishing intimacy.

Lack of partners. There’s no sex without a partner. Duh! Demographics and life expectancies being what they are, the older we get, the fewer our options for partners.

Some of us may be able to date casually or to self-pleasure for sexual release, but for others, this may not be an option. Again—no easy answer.

Making peace with the situation. “Normal” covers a lot of ground. And while we clinicians are always seeking to define it, the fact is that “normal” for one patient may be very different for another.

Despite all the impediments and changes, I’ve found that women generally find their way to a sense of equilibrium with regard to their sexuality. And we clinicians have to respect that.

You define what’s normal for yourself. If you are at peace with your decision to abstain from sex, then abstinence is normal for you. Likewise, if you choose to be sexually active well into your nineties, then that’s also normal.

However, if you experience frustration, anxiety, discomfort, or pain regarding your sexuality, then you should bring this up with your healthcare provider. We can help, and sometimes the solutions are simple.

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View from the Trenches

Dr. Susan Kellogg Spadt on Sex and Aging

Have I mentioned recently what a great team of medical advisors is associated with MiddlesexMD? We regularly draw from the wisdom and experience of leaders in the field of aging and sexuality. In the next two posts, we’ll hear from Dr. Susan Kellogg, who is not only one of our esteemed advisors, but who also co-founded and directs the Pelvic and Sexual Health Institute in Philadelphia. Read on as Dr. Susan shares with us some of the barriers to sexuality for older women. And thanks, Susan!

In my practice I regularly see women in their 60s and 70s. What often impresses me is how unique each is in her experience of sexuality.

Some still like sex and remain sexually active, while others just aren’t interested—even if they have a functional partner.

Of course, there’s been a lot of research, mostly on the age-related changes men experience. I think this is because male sexuality is more straightforward. With women, as has been said elsewhere on MiddlesexMD, it’s complicated.

So, let’s look at some of the impediments to sexuality for women as they age.

Internalized ageism. We absorb cultural messages all our lives. They bombard us from the media, from religion, maybe from the region we live in or the ethnic group we belong to. The messages can be subtle (“Good girls don’t…”) or they can be in-your-face (“You’ve come a long way, Baby.”)

While the messages have shifted over the years, some are inconsistent and some remain the same. For example, one consistent message is that “real” men remain sexually active as they age. (Which, I’m thinking, can be pretty tough on men, too.) For example, an older man’s ability to attract (and, presumably, to satisfy) the “trophy” wife is a status symbol synonymous with wealth, virility, and power.

The messages are mixed for older women. It’s desirable to be a “cougar” in your 40s and 50s, but the ground shifts subtly after that. Despite the sexual older woman portrayed by the Golden Girls, or by Diane Keaton in Something’s Gotta Give, or Meryl Streep in Mamma Mia, the word on the street is that we older women ought to settle gracefully into our roles as the sexless Grandma. A foxy granny just doesn’t play well.

We, in turn, can be very sensitive to these cultural expectations, and we can allow them to define us. We can internalize them.

In fact, research suggests that gay men and heterosexual women are highly susceptible to internalizing cultural messages that equate aging with loss of interest in sex.

When we implicitly assent to the message that we’re old and therefore no longer sexually attractive or viable, it can affect our self-esteem and our experience of sex and intimacy. The message is false, and believing it is a shame.

Sexual scripts from families-of-origin. Just like societal messages, we absorb beliefs and assumptions about sex from our families. They can be deeply imprinted on our young minds, and they don’t have to be clear or verbalized. In fact, our families are often the first place we learned about sex.

Did our parents smooch and cuddle or were they cold and distant? Did sex seem natural and loving or was it something shameful and dirty? Did the sex stop at some point? Did they move to separate beds or separate bedrooms? Did this seem to be expected at a certain age?

Women commonly internalize direct and indirect messages about aging and sexuality from family members. Usually, we’re not even aware of it.

Low self esteem. It’s hard enough to maintain a strong sense of self-worth in this world without the added insult of getting old in a culture that absolutely idolizes youth and beauty.

We may have survived the adolescent jungle and our family of origin with, I hope, few scars. Many of us have struggled with self-esteem, and that struggle has only changed, not ended.

Now we’re hit with an entirely new challenge: how to maintain our confidence and positive self-image as we grow old in a culture that seems to have no use for us simply because we’re not young.

It’s unfair and it’s insulting, and it takes a strong sense of self to stand against that bias.

Unfortunately, for some women, feelings of low self-worth become an impediment to sex. I think this is why some women complain about feeling unattractive and losing desire. It’s hard to feel sexy when you feel dowdy and useless.

One client even said that when she saw her sagging breasts in the mirror she felt that she did not “deserve to have sex.”

The truth is, of course, that beauty has a lot more to do with confidence and creativity than with perfectly taut skin. Cover up the mirrors. Be proud of your wrinkles! You’ve earned them.

To be continued…

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The new medical guidelines and what they mean for you.

Every year, you used to visit your ob/gyn for a Pap test and pelvic exam. Then you’d get your mammogram. Some ladies I know made it a “girlfriends date” and went out to lunch after their mammos.

It was like getting your healthcare seal of approval. All’s well with the world. See you next year.

Now the “guidelines” have changed. You’ve heard that you don’t need these tests every year. In fact, depending on your age and health status, you may not need them any more at all.

Wait, what? Who re-arranged the furniture? What does this mean?

And more to the point: What happens to the girlfriends date?

With a slew of new guidelines from the American Cancer Society and the American College of Obstetricians and Gynecologists (ACOG) and the US Preventive Services Task Force, it’s no wonder you’re confused. One year? Three years? Beginning at what age? Ending when?

These guidelines reflect new thinking and research, not the removal of a time-honored safety net. You won’t be at greater risk—you just may not need the same tests on the same schedule. Also, different professional groups have come to slightly different conclusions about how often these preventive tests should be administered.

So, while it’s helpful to be aware of these changes, it’s also critical to discuss them with your own healthcare provider. Because your healthcare situation is unique, and guidelines are one-size-fits-all, the schedule has to be tailored to fit your specific needs. You and your doctor are the best ones to make that decision.

Here’s what some of the discussion is about.

The value of an annual physical, which ACOG also refers to as a “well-woman visit,” is that your doctor can examine and assess your overall level of health and can check for changes or abnormalities. A regular visit also keeps intact the relationship between you and your doctor. After all, it’s important to trust this person when healthcare decisions need to be made.

During your annual physical, your provider may do a pelvic examination. Herein lies some confusion. A doctor may, and often will, do this exam without a Pap test. A pelvic exam allows the doctor to take a thorough look at your external genitalia and to digitally (yes, with a finger in your vagina or rectum) examine your cervix, uterus, and other internal organs.

In its new guidelines, ACOG recommends an annual pelvic examination in women over 21. But the guidelines also state that, while an annual pelvic exam “seems logical… No evidence supports or refutes the annual pelvic examination or speculum and bimanual examination for the asymptomatic, low-risk patient.”

Translation: in the absence of symptoms, the final decision is up to you and your doctor. Pelvic exams are also important if you have any pain, discharge, bleeding, or change in bowel or bladder function. Your doctor needs to know about any of these issues.

As for the Pap test—you probably know that it only screens for cervical cancer—it’s been a very effective tool in that regard. But many women don’t need screening for cervical cancer anymore—if they no longer have a cervix, if they’ve had several normal pap tests and don’t have a lot of sexual partners.

Be aware, however, that there are other cancers of the genitals and reproductive organs, and I’ve occasionally found them during a pelvic exam: You’d better believe I still recommend an annual physical that includes a pelvic exam for my patients.

The guidelines for mammograms are even more confusing. The American Cancer Society still recommends annual screening after age 40. However, the US Preventive Services Task Force recently revised its guidelines after analyzing data extensively, to screenings every two years for women over 50. Women over 74 no longer need mammograms, according to the Task Force.

Meanwhile, physicians routinely do manual breast exams in their offices. That’s the kneading, palpating exam the doc performs to check for changes and lumps. While ACOG and other organizations still recommend a clinical breast exam every one to three years, the US Preventive Services Task Force says that “current evidence is insufficient to assess the additional benefits and harms of clinical breast examinations….”

So, what’s a woman to do?

Again, talk with your doctor. It’s good to be informed about changing guidelines and protocols. These changes only mean that research is ongoing and the body of knowledge is increasing. But you have unique risk factors, heredity, health issues, fears, lifestyle choices, and preferences. The best way to make sense of the guidelines is to discuss them with your provider in light of your personal situation, and then come to a conclusion that you’re both comfortable with.

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Estrace is a bio-identical form of estradiol, a plant-based version of the same estrogen made by our ovaries. It comes in two forms—oral (systemic) and vaginal (localized). I use very little oral estrogen in my practice, because we’ve learned that transdermal estrogen (delivered by patch, gel, or spray or other forms that deliver it through the skin) is safer than oral. Because it’s not metabolized by the liver, it doesn’t carry the same risk of thrombosis.

Vaginal Estrace is great from a therapeutic perspective—that is, it’s very effective for treating vaginal atrophy. Because it’s a cream, though, many of my patients don’t love it: Some find creams messy to apply. It’s important to find a form of localized hormones that each patient will actually use!

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Ladies, sometimes we are just too full of ourselves.

Yeah, it’s tough growing older in a society that adulates youth. It’s especially distracting in bed: Does he see the cellulite on my thighs? When I’m on top, my belly sags like a pregnant dog, so let’s stick to the missionary position. While we’re at it, nothing stronger than a candle. One candle.

Of course, our secret vulnerability is that we yearn, in the secret recesses of our still-adolescent souls, to be desired. To have the person we love (or maybe someone who looks like George Clooney) think we are the most beautiful creature he’s ever seen. In such a way that we know it’s true.

And, of course, as we discussed before, everything in our culture, in our psyche, and maybe even from our family of origin rewards youth, beauty, and thinness. And we are not those things any more.

But what about men?

Aren’t they unscathed by cultural expectations about sex and intimacy? They created them, didn’t they? And they don’t have to be in the mood. They don’t have the same, um, unpredictabilities when it comes to getting it off in bed. Things are just more straightforward for guys.

Not really.

I’ve been doing some reading lately, and it’s given me a different perspective on Mars. The cultural messages and expectations they absorb almost from the cradle are equally potent and can be equally unrealistic and even damaging. And part of the message is that they aren’t supposed to talk about it. No whining, no complaints, just be a man. Get it up and get her on.

Consider this observation from a researcher who has interviewed men (and even more women) for many years: “… From the time boys are from eight to ten years old, they learn that initiating sex is their responsibility, and that sexual rejection soon becomes the hallmark of masculine shame.” She heard this from a man she interviewed:

“Even in my own life, when my wife isn’t interested, I still have to battle feelings of shame. It doesn’t matter if I intellectually understand why she’s not in the mood. I’m vulnerable, and it’s very difficult.” (From Daring Greatly by Brené Brown).

I encounter this sentiment repeatedly. Men are vulnerable too. Because they usually initiate, they can be rejected. And they’re “responsible,” not only for their own orgasm, but in some way for ours. After all, if they were slower or faster or lasted longer or were more skilled….

There’s a reason for performance anxiety in men. A lot is riding on that “performance.” They don’t articulate it, not even to themselves, but their self-worth is connected to “performing” well. And if we don’t get off, or, God forbid, if they don’t, the result is shame.

“A guy can’t get through the day without seeing an ad for an erectile stimulant, getting spam about some sort of penis enlargement pill, or hearing sexual tall tales from the guys in the locker-room,” says Ian Kerner, author of She Comes First. “We live in an age where a lot of guys feel like they have to make love like porn stars, and with all the cultural reinforcement, it’s hard to believe otherwise.”

When you think about it, ladies, who are the male role models put before our men and boys? Wouldn’t the Disney Princess counterpart for boys look something like GI Joe or the Terminator? And for men, according this Esquire list, it’s George Clooney (who “eats class for breakfast”) and Liam Neeson. (Actually, the list is incredibly thoughtful and diverse. Check it out.)

But the point is that social pressure on boys to be “men,” and how we define “manly” is every bit as intense and constricting as is the pressure on us to be young, beautiful, and thin. And performance in bed is absolutely integral to the definition of being manly.

“Sexual prowess is the Holy Grail of manhood,” writes Scott Alden. “More than success, more than athleticism, more than witty banter—if we’re not a killer in the sack, we’ve failed as men.”


But what is really sweet, actually, and vulnerable and heartbreaking is that the thing your man wants most—even if it’s buried deep inside under years of habitual behavior in bed and out—the thing your man want most, is to turn you on and to know that he did it.

Truth. Nothing is sexier to a man than to turn on the woman he loves.

“For men, there’s nothing sexier in a woman than awakened desire,” writes Alden. “We also have a deep-seated need to keep our mate committed to us, and pleasing her better than anyone else in the history of sex has ever pleased anyone would be a good way for us to do that.”

All of us—men and women—are stereotyped in unhelpful ways by our time and culture. We’d probably have a lot more fun if we understood the forces that form us and viewed each other with a little more compassion.

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