Archive for November, 2013

What you describe could well be vaginismus, which is the involuntary spasm of pelvic floor muscles of the outer (lower) third of the vagina. The resulting interference with intercourse is experienced as “too tight,” “he can’t get in,” or “it’s like he’s hitting a wall.”

Because the spasm is involuntary, the cause is sometimes difficult to understand. Pain in the area of the pelvis can be a contributing factor, so the hip pain you describe is likely involved. Beyond interfering with intercourse, vaginismus–those pelvic floor muscles in spasm–can also be experienced as pain in the pelvis, low back, low abdomen, and upper thighs.

It’s important to have an exam to better understand what’s happening for you, and I’d advise that you have the exam sooner than later. If you have surgery in your future, physical therapy that starts before-hand (and continues after) could help in your recovery, too. Vaginal dilators are often a part of therapy for vaginismus, and that, too, can start now and deliver benefits for your recovery.

Good luck in working through this! With patience and good information, you can do it.

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You mention a variety of things that play a role, all coinciding with the change in hormone levels that comes with menopause, which you’ll reach in a few more months (the milestone is one year without menstruation).

The Vagifem that’s been prescribed for you should be having some positive effect with vaginal dryness; it should not interfere with orgasm. Vagifem is a very, very low dose of estrogen, delivered directly to the vagina and surrounding tissues. This is partial compensation for the estrogen delivered through the whole body when ovaries are intact and functioning.

SSRIs (selective serotonin reuptake inhibitors, a type of antidepressant), which you mention taking, can be a barrier to orgasm. If you’ve taken them for a while and only recently have had issues, it could be that the combination of the SSRIs and the lower hormone levels of menopause is now problematic. There is limited evidence that Viagra can help women on SSRIs experience orgasm. It’s not just estrogen that declines with menopause: Testosterone also declines. You might talk to your health care provider about testosterone therapy; among my patients, many who trial testosterone note sexual benefits, usually describing more sexual thoughts, more receptivity (a patient recently told me she’s “more easily coerced”!), and more accessible orgasms.

You also said that vibrator use has become ineffective for orgasm. Among midlife women, I find that the specific vibrator really counts. There is a definite range of vibration intensity, and as our bodies change, that can make all the difference. Lelo has just doubled the “motor strength” of two of their already powerful (and MiddlesexMD favorites) vibrators for the Gigi2 and Liv2.

Best of luck! My work with women every day says it’s worth exploring your options. (And, to take the pressure off, remember that intimacy without orgasm is still intimacy!)

To ask your own question, use the pink “Ask Dr. Barb” button top and center on our website. You’ll receive a confidential reply via email, and your question may be used as the basis for a Q&A post here on our blog. 

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It’s highly unlikely that Estring would cause liver damage, so no, you needn’t be concerned. Estring releases estrogen locally, in the vagina; this is not metabolized through the liver. We do know that women with significant liver disease are not good candidates for oral estrogen, which is metabolized through the liver.

The warning label you read is required by the FDA for all estrogen products, even though the same risks are not posed for all forms. There’s a request pending with the FDA to change this “class labeling” to be less confusing.

In the meantime, your history is not a reason to avoid a localized estrogen product.

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Few things affect quality of life like lack of sleep. Nothing kills the jazz or even dulls the everyday ho-hum routine like that head-in-a-fog, feet-in-the-mud feeling of too little sleep.

And sex? Romance? That delicate dance we do to stay connected with our life partner? Fuggedaboudit. We’re having enough trouble keeping our heads up and off the desk at work. All we want is a good night’s sleep, and that’s the very thing that’s as elusive as a four-leaf clover in an alfalfa field.

If you haven’t discovered already, insomnia is the dark shadow of the menopausal years. (And insomnia can begin years before other menopausal symptoms and can last long after other symptoms subside.) In fact, almost half of women age 40-64 report having sleep problems, according to a 2007 National Sleep Foundation survey. Compared to premenopausal women, those in peri-and post-menopause report sleeping less, sleeping badly, and are twice as likely to use prescription sleep aids.

Yuck. That’s a lot of cranky, sleep-deprived women.

As you might expect, menopausal insomnia can be caused by a lot of things—hormonal changes, for one.  “With impending menopause, most women experience a reduction in progesterone and estrogen,” says David Slamowitz, MD, medical director of the SleepWell Center in Denver, in this article for More magazine. “These hormones help regulate sleep, so declining levels can cause sleeping difficulties.”

Better sleep may be another reason to consider hormone therapy.

But these years are often associated with change in our careers, health, children, parents, and partners. Change is stressful, and stress is the archenemy of sleep. If you’re anxious about your health (or your parents’ or your partner’s), if your children are adjusting to adult life, if you’re having difficulty covering the demands of your job, it’s hard (or impossible) to drop these worries at the bedroom door.

Other causes of sleeplessness can be the physical insults of getting older—arthritis, frequent nighttime urination, sleep apnea, restless leg syndrome. Not to mention the misery of hot flashes and night sweats, which can awaken us several times a night. The only mercy here is that if we can make it to blessedly sound REM sleep, hot flashes tend to lose their power to wake us up.

So, what is a foggy-brained, sleep-deprived, menopausal woman to do?

Well, first, if you snore, feel depressed, or find insomnia to be seriously affecting your ability to function, talk to your doctor. You may need to tease out how other factors may be influencing your sleep. Review the medications you’re taking, which can also interfere with sleep (and sex). Ask him or her to check your thyroid for an endocrine disorder that can disturb sleep.

But you have some control over your sleep (or lack thereof) as well. You can be proactive about getting a good night’s sleep. Plus, good sleep hygiene often ends up being good for your overall health as well. (You knew we were going there.)

Here’s a regimen that may have you sleeping, if not like a baby, perhaps almost like a normal human being.

  • Exercise. Vigorously in the morning with maybe a bit of gentle yoga in the evening.
  • Get outside when you exercise. Natural light helps establish a good sleep-wake cycle, and we tend to become more housebound as we age.
  • Don’t nap. Yeah, this can be tough when you haven’t slept at night, but we’re moving toward establishing a rhythm here.
  • No stimulants. Obviously, a double latte at 8 p.m. will keep you jittery into the wee hours, but avoid caffeine in any form, including chocolate. Ditto for nicotine and alcohol. Contrary to common (mis)perception, alcohol will relax you at first and wake you up later when your body begins to metabolize it.
  • Don’t eat heavily before bedtime.
  • Establish a soothing bedtime routine that sends “now we’re getting ready to sleep” signals to your brain. And do it at the same time every evening. (That rhythm thing again.) Drink an herbal tea. Read a book. Do your yoga. Don’t watch TV or do computer work if it winds you up. Don’t engage in stressful conversation in the evening.
  • Make the bedroom pleasant and sleep-inducing. It should be dark and cool but not cold. The bed should be comfortable and you should use it only for sleep—and sex. Oh yeah, remember that?

With any luck, you’ll gradually move beyond this tough transition and slowly reestablish more normal sleep patterns as your hormones settle down. But as with many issues during menopause, we may need to adjust to a new normal as well. Some women say they’ve been able to make their peace with and adapt to different sleep patterns.

And whether we’re talking about sex or sleep, adaptation is what it’s all about right now.

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It sounds like you’ve done a great job with regular, sustained use of dilators to restore the vaginal opening. Be aware that the top of the vagina tapers a bit, so it’s possible that the largest-diameter dilator, because of its width, just won’t go in as far as the others. The only way to assess for certain what’s happening is to have a pelvic exam with your health care provider; I’d explain to her or him that you’ve been using dilators and see whether s/he finds anything other than normal.

During intimacy with a partner, many women find that they can control the depth and angle of penetration more easily when they are on top. That seems to be a safer starting point for women who have reason to better understand what’s most comfortable–and pleasurable.

Congratulations on taking care of yourself!

To ask your own question, use the pink “Ask Dr. Barb” button top and center on our website. You’ll receive a confidential reply via email, and your question may be used as the basis for a Q&A post here on our blog. 

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Chocolate/vanilla. Black/white. Either/or. By now we know that life is a lot more nuanced. It’s an infinity of shades of gray. (Also a lot more flavors of ice cream.) Recently, a quiet phenomenon is gathering steam that challenges the either/or notion of sexuality and attraction as well as the theory that sexual orientation—our attraction to boys or girls—is pretty rigidly in place by adolescence.

They call themselves the “latebloomers.” These are women who discover well into middle age and often to their utter surprise, that they are sexually attracted to other women.

In a previous post, I wrote about some studies that examined arousal in men and women. Men, if you recall, are turned on by straight-up heterosexual sex. (Gay men are turned on by scenes of homosexual sex.) And they made no bones about their level of arousal in their self-reports, which were totally consistent with their physiological levels of arousal, as measured by blood flow to their genitals.

Women, on the other hand, were turned on by a wide variety of sexual pairing, including scenes of primates mating, according to those same instruments. But they reported that they were only aroused by heterosexual sex, which was decidedly not what their bodies were saying.

Interesting, hey?

So, that makes me wonder about this groundswell of latebloomers. By and large, they are stable, mature, married women with children who had never before been attracted to women, but who suddenly and unexpectedly found themselves with feelings they had never experienced before.

As you can imagine, this realization is like a land mine in the middle of the kitchen floor, causing tremendous upheaval, both to the woman’s identity and, if acted upon, to all her close relationships. When mamma comes out as a lesbian, it can alienate children, shock extended family, and destroy marriages. (Although interestingly some women manage to continue living with their husbands, albeit in a renegotiated relationship. Others found their husbands remarkably sanguine once they understood that it wasn’t about some shortcoming in themselves.)

Women who’ve made this transition often say it’s like discovering themselves anew. “It’s as if you spoke Chinese and lived in Mexico, then went back to China and could suddenly understand everything,” says Micki Grimland, who left a 24-year marriage after realizing she was gay in this article for More magazine. “Being straight was my second language, and I didn’t realize it until I found my first.”

Science has come a long way from the time when homosexuality was considered a mental illness. Still, sexual orientation was thought to be partly genetic and fairly hardwired by the time a person completes adolescence.

Yet, maybe things aren’t so black and white. Maybe sexual attraction isn’t so rigidly defined, at least for women. Among women in their 40s who now live with a same-sex partner, 35 percent had been married to a man. Among women in their 50s, that number is over 50 percent; and 75 percent of lesbian women over 60 had once been married.

By contrast, “almost 100 percent” of men were aware of their homosexual tendencies when they got married, according to Eli Coleman, director of the human sexuality program at the University of Minnesota in the More article. “Many women, though, are unaware of same-sex attraction until they’re much older.” And I’ve heard some discussion that women, who value deep emotional connections and communication, find that connectedness more readily later in life with women than men.

“The Kinsey scale shows women’s sexuality as very fluid,” says Barb Elgin, a social worker and relationship coach in this article.

There simply isn’t enough scientific data to make any firm statements about female arousal or sexual orientation or about how changeable and fluid it may be over the course of a lifespan. At this point we’re mostly relying on anecdotal evidence. But that may be enough to suggest a cautious and compassionate approach to the issue, especially if you know, as I do, several women who have made this difficult crossing.

Because life just isn’t black or white.

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Localized estrogen is not thought to be absorbed systemically, which means that blood estrogen levels remain in the menopausal range; if there is any absorption, it is scant. At that level, it does not increase risks of breast cancer. Unfortunately, the “prescribing information” (PI) for localized hormones is required to be the same as for all estrogens, although the risks are significantly different from those of systemic estrogens.

Last month, I attended the North American Menopause Society (NAMS) annual meeting, where I heard that a request has been filed with the FDA to amend the PI to fit more accurately what’s known about localized estrogen use.

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