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Even though vaginal dilators have been around for decades, they still elicit lots of attention and a few quizzical looks even from healthcare professionals whenever we display our wares at medical conferences. My patients sometimes have questions, too, and we get phoned-in and emailed questions here at MiddlesexMD.

Dilators are one of the most straightforward medical devices you’ll run across. They are a set of tubes that gradually increase in diameter from about a half-inch to about an inch and a half. They are usually made of high-quality plastic, but may also be made of silicone, which gives them a softer, more flesh-like quality. Both types are washable with soap and water. Dilators are used to increase vaginal “patency,”—its capacity and ability to accommodate the things that vaginas are made to do, like a speculum, a baby, a penis—some pretty important stuff, in other words.

Dilators are used to:

  • Prevent scar tissue from forming after some cancers or pelvic radiation therapy.
  • Increase vaginal capacity and length after certain procedures, such as a total hysterectomy.
  • Maintain vaginal capacity during times when sex isn’t an option for whatever reason.
  • Improve vaginal capacity after a long time without sex (remember the old use it or lose it adage).
  • Help to address vaginal shortening and tightening due to hormonal changes of menopause.
  • Treat conditions, such as vaginismus, that make penetration difficult.

Since some vaginal conditions might require additional treatment, such as localized estrogen or muscle relaxants, you should always discuss any vaginal pain or change in your ability to have sex with your doctor, as well as how you might benefit from using dilators. From there, if it’s simply a matter of conditioning or maintenance, our shop has a selection of high-quality plastic and silicone dilators.

I recommend any of these sets. Choose the features and sizes that appeal to you. The first set that we found and offered remains a favorite. It’s available with five or seven dilators, depending on your starting point, and the straight, solid cylinders are easy to handle and clean.

The silicone kit is firm yet flexible with a softer touch. (Bright colors don’t hurt, either.) Be aware that silicone lubes will degrade the surface of these dilators, so use them only with water-based lubricants.

The Amielle kit is our high-quality, good-value choice. This set of five dilators is made of medical-grade plastic and includes a detachable handle that might make insertion easier.

Increasing vaginal capacity takes patience—often several months. For maintenance, you may need to use dilators regularly until you’re having sex regularly. The goal is to accommodate your partner’s penis (or your doctor’s speculum) comfortably and without pain. It’s a worthy goal, so accept that you’re in it for the long haul.

To use dilators:

  • Start with a warm bath to soften tissues and relax your pelvic floor muscles (along with everything else).
  • Find a comfortable and private place and lie down on your back, legs bent at a 45-degree angle and shoulder-width apart.
  • Consciously relax all your muscles, from head to toe. Do a mental scan for areas of tension around your eyes, brows, or anywhere else. Focus on breathing in; breathing out.
  • Begin with the smallest dilator and slather it with high-quality, water-based lubricant. (Not petroleum jelly or any kind of oil.) Generously lube your vaginal entrance as well.
  • Gently insert the dilator until you meet resistance. Pause. Breathe. Practice kegel exercises. Insert it a little farther if you can do this without discomfort. The dilator should fit snugly but without pain.
  • Keep it in place for twenty or thirty minutes. Watch TV or listen to a podcast or your playlist. Practice kegels.
  • You can try rotating it in place or moving it in a circular motion around the vaginal entrance or gently moving it in and out.
  • Clean with soap and water. Towel dry.
  • Move to the next size when you can comfortably insert the smaller one.
  • Do this 3-4 times per week or every other day.

You may bleed a little at first. This is normal. But if you soak a sanitary napkin or experience frequent bleeding, this is not normal. Stop using the dilator and call your doctor.

I like dilators because they’re both simple and effective. Granted, taking a pill is easier, but there are no pills that treat vaginal patency as such. If you stick to the regimen, dilators are very effective in both reconditioning the vagina and in maintaining elasticity during fallow sexual periods.

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You asked. Dr. Barb answered.There are plenty of bioidentical pharmaceutical hormone options to treat menopausal symptoms. Over 90 percent of my hormone therapy patients use these, and most physicians who treat menopause are familiar with the options. There are brand name and generic products available; to list some of them: Estrace, Vivelle, Minivelle, transdermal estradiol, Prometrium, micronized progesterone.

You also mention weight gain. I hope you know you’re not alone! We had a series on this topic this summer that may be of interest to you: an overview of the reality, how you can respond with diet alterations, and how exercise can play a part.

If you need a provider who focuses on menopausal treatments you can find one on the NAMS website (North American Menopause Society) at this link. Enter your zip code and a list of nearby providers will be listed.

Good luck!

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You ask whether there’s effect on your pH level from swimming several times a week in a chlorinated pool and whether inserting a tampon would provide some protection. The vagina is, in its natural state, not an open space but collapsed, that is, the walls are lying next to each other. Imagine a balloon before it is blown up. We refer to the vagina as a “potential space,” because space is made there only when needed—for a tampon, childbirth, or sex.

The vaginal pH isn’t disrupted with a relatively brief swim or tub bath. Inserting a tampon actually would be more likely to act as a wick, introducing more chlorinated water because of its absorbency.

Chlorinated water certainly can affect the vulva and surrounding skin; I do hear that from a number of patients. In that case, be sure to rinse thoroughly after swimming, and then apply a product like Lubrigyn Lotion (available in wipes, which you can put in your bag to take to the pool) to soothe by moisturizing.

 

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Among other things, sex is a nice aerobic workout. You breathe hard; your heart rate goes up, as does your metabolic rate. You burn calories. (Yay!)

Therein lies the rub for us older folks.

Isn’t the stress on the cardiovascular system dangerous for anyone with a heart condition? Especially if he or she doesn’t know about it? Or, even when the doctor gives you the green light to have sex, the specter of a sudden attack always looms in the background.

“I think it’s important to healthy relationships to have this anxiety lifted,” said Dr. Michael Ackerman, professor of medicine at Mayo Clinic. “[People] always ask about exercise and how active they can become,” he said in this article. “They almost never ask directly about sex,” but, once it’s mentioned, he said, ”the floodgates open.”

Now, a large and robust study provides the most detailed picture we’ve even had of the actual numbers of people who suffered a fatal heart attack during sex. Researchers examined lifetime medical records from 4,557 people in Portland, Oregon, who died of a sudden cardiac arrest from 2002 to 2015.

Of the 4557, the number of people who died of a heart attack during sex or within an hour after?

34.

That’s it. Thirty-four people ranging in age from 37 to 83. Of that number, 32 were men. Thus, the risk of having a heart attack during sex in men is 1 percent, while for women, it’s .1 percent. While doctors always knew the risk of heart attack was slim, now that the risk is quantified, even researchers were taken aback. “I’m a little surprised at the really tiny number,” said Dr. Sumeet Chugh, senior author of the study and a professor of medicine at Cedars-Sinai Heart Institute in Los Angeles.

It goes without saying to follow your own doctor’s instructions for activity if you have a heart condition. But if you’re given the “all clear” for sexual activity, I hope these numbers put your mind at ease. No need to abstain from one of life’s sweetest pleasures.

“[This is] a wonderful answer for those who love sex,” said Dr. Ackerman. And, I might add, for those who recognize the link between sexual health and overall good health.

 

 

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For nigh onto 30 years, the North American Menopause Society has encouraged research into and disseminated information about all things menopause. It’s the hub of the wheel for healthcare professionals and individuals alike seeking the latest scientific information and objective advice about “the change.”

One presentation at this year’s annual meeting in October struck me as particularly apropos for MiddlesexMD readers—part refresher course; part new information. So I’d like to pass it along.

In a wide-ranging talk, Dr. Nick Panay, a gynecologist from Great Britain, explored current understanding of that most common and persistent problem of menopause: painful sex due to vaginal dryness. He reminded us that lots of women will suffer from it (about half of women at some point in life), and that many won’t mention it to their doctors. He encouraged healthcare workers to ask: “If you don’t ask, women often won’t volunteer the information.”

So far, so good, but ground that’s been covered.

Everyone likes sex better with good lubrication, he said, and women often expect their bodies to lubricate adequately, just like they did “before,” so when they inevitably don’t, it’s a real buzzkill for sex.

This state of affairs can be tackled in many ways—topical estrogenOsphenaIntrarosa, and the good old stand-by, moisturizers and lubricants. According to Dr. Panay, moisturizers and lubes can provide relief from vaginal dryness, but they don’t address the underlying cause, which is loss of estrogen. Only estrogen can do that.

Turns out, however, that a couple additional considerations might affect how your body reacts to a specific moisturizer and/or lubricant, depending on its ingredients. In this report, Dr. Panay mentions three physical characteristics of the vagina that might be altered by components in what we put there.

  • pH balance. A healthy vagina is slightly acidic with a pH value between 3.8 and 4.5. Ideally, whatever lubricant or moisturizer you use should be close to those values to retain the vagina’s protective bacterial balance.
  • Osmolality. This is a fancy concept that refers to the amount of particles dissolved in a liquid. High osmolality has a lot of “stuff;” low osmolality doesn’t. The way this works in the vagina is that, ideally, equilibrium is reached between vaginal cells and the moisturizer or lube, depending on its osmolality. When the osmolality is off-kilter, it either draws water from vaginal cells or over-moisturizes them, either of which could cause changes in the vagina. In a test of several products on slugs, for example (yes, like you see pictured below), which as we know are all about moisture and mucus, products that were hyper-osmolalic (high levels of particles) irritated the slugs a lot.
  • Additives. Ingredients like glycols, parabens, and preservatives, which are found in some products can also irritate the vaginal lining, kill good bacteria, and increase susceptibility to infection.

Ideally, says Dr. Panay, the lube/moisturizer you use should be as close to vaginal mucosa as possible—a product that is “optimally balanced in terms of both osmolality and pH and is physiologically most similar to natural vaginal secretions.”

slug like those used for testingTrouble is that the ingredients in a moisturizer or lubricant aren’t always listed on the label and identifying those with correct osmolality and pH levels is fairly impossible for the average user, especially since a product with a good pH level might have bad osmolality numbers. Dr. Panay shared the results for several dozen products available worldwide, and we were happy to see that YES VM, a moisturizer, and YES WB, a lubricant, both scored very well in the testing (we shouldn’t be too surprised, since they’re both very popular in our shop).

So what’s the practical application for all of this new data? For us at MiddlesexMD, we’ve got some new criteria for vetting and recommending products from our shop (sadly, Dr. Panay’s tests couldn’t include every product currently available). We hope that makers of moisturizers and lubricants will take these new findings into account in their formulations, and we can now ask for data on osmolality in addition to pH levels when we evaluate products.

For you, keep in mind that lubes and moisturizers are the first line of attack in making sex comfortable (or possible) and in keeping vaginal tissue flexible and moisturized. According to Dr. Panay, this is true even if you use topical estrogen or another drug, such as Osphena or Intrarosa. Choose your products carefully, looking for high-quality products that are free of glycol, parabens, and other additives.

Pay attention to any increase in vaginal irritation or infections. Your lubricant or moisturizer could be contributing. Don’t give up on lubes or moisturizers, though: Try another product or formulation that’s a better match for your pH and is providing the right amount of moisture to your tissues.

 

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You say your wife has lichen sclerosis and uses Estring, a ring placed in the vagina to provide localized hormones; she has difficulty doing Kegel exercises correctly.

You asked. Dr. Barb answered.The Intensity is very effective at contracting the pelvic floor muscles, which is does with electrical stimulation through specially designed electrodes. Contracting the muscles builds muscle tone, and it sounds like you and she are aware of the benefits of pelvic floor strength: keeping organs in their places, preventing incontinence, and strengthening orgasm.

The lichen sclerosis should not be a limitation in using the Intensity. Because the electrical stimulation works best if the Intensity is expanded for full contact with the walls of the vagina, it would work best if she slips the Estring ring out before using the Intensity, and reinserts it after. Otherwise the ring will prevent full contact and limit the effectiveness of Intensity use.

I hope this is helpful!

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A Natural Alternative to Soy

Every now and then, I’m asked about herbal or other plant-based remedies for hormonal symptoms. There’s another botanical treatment that appears to have some staying power in the U.S. marketplace.

Relizen is a plant-based treatment for hot flashes and night sweats that has a solid clinical track record. What’s more, it doesn’t have one of the major drawbacks of the soy products we discussed a while back—phytoestrogens.  These are the botanical imitators of estrogen that have received mixed reviews in scientific studies—some suggesting that they act too much like estrogen in the body and some suggesting that they actually work to protect against the effects of estrogen.

Relizen, on the other hand, has no estrogenic effects. It is made from the pollen of flowers that grow in southern Sweden. Very poetic, I know. It was developed by a Swedish doctor who also happens to be a biologist and a beekeeper and who apparently was a close observers of his bees’ collection habits.

I know what you’re thinking: Pollen=allergies! But our Swedish doctor invented a process that removes the allergenic husk from pollen and processes only the cytoplasm—its nutrient-rich inner core. And voilá!—a totally natural and non-estrogenic product that just happens to work very well to relieve vasomotor symptoms (VMS) in menopausal women.

Unlike a lot of botanicals, Relizen has been clinically tested with results published in peer-reviewed journals such as Climacteric, and Menopause. In these studies, Relizen significantly reduced hot flashes without raising hormone levels after the first month of use compared to a placebo.

Additionally, after three months of use (you have to be patient here), up to two-thirds of the 400 women surveyed reported improved quality of life, not only due to a reduction in frequency and intensity of hot flashes and night sweats, but also because of a reduction in irritability and fatigue.

Aside from these studies of efficacy, the big advantage for women who want to stay away from anything with estrogenic qualities or women who are taking tamoxifen is that Relizen is safe. According to statements by Dr. Steven Goldstein, professor of OG/GYN at New York University, at the 2014 North America Menopause Society meeting, “Tamoxifen creates some of the worst hot flashes we will ever see.” Yet, after reviewing the clinical results, Dr. Goldstein feels that Relizen is safe for tamoxifen patients.

“It is the only nonpharmacologic product that I have ever been aware of that has a double-blind, randomized, placebo-controlled, parallel study showing that it reduces vasomotor symptoms and improves quality of life in menopausal women,” he added.

In my own clinical experience, several patients have responded well to Relizen, and like Dr. Goldstein, I have no concern about estrogenic interactions.

Relizen is taken as two tablets daily, and it might take up to three months to take effect. It’s been on the market for 15 years in Europe with over one million users, and it is one of the best-selling menopause products in France. While it can only be ordered online, and it isn’t inexpensive, Relizen may be worth a try for women who’ve tried everything else or for those who want to avoid drugs and hormones.

 

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