Archive for the ‘Under the Covers’ Category

It would be very, very unusual for an old episiotomy scar to become problematic. You say you experience dryness, irritation, and a “tearing feeling,” which sounds to me entirely consistent with vulvodynia (also called vestibulodynia or provoked vulvodynia). Other ways the pain has been described are “sandpaper,” “cutting,” or “ripping.” The most common experience with vulvodynia is pain with intercourse, and usually not with other activities (although sometimes women have sensitivity when wiping after urination). There may or may not be vaginal dryness.

If the pain you’re experiencing is related to atrophy, which is very common and usually evident by vaginal dryness, the Premarin vaginal cream you describe using should be quite effective for that. A topical steroid, which you’ve also been prescribed, would be helpful if there’s an identified vulvar skin condition or dermatosis, but I’m not sure any of your descriptions indicate that the steroid is beneficial. You also asked about the Mona Lisa Touch, which has been shown effective for atrophy, but not vulvodynia, at least thus far.

For patients with vulvodynia, I use a compounded prescription of low-dose estrogen plus testosterone applied to the opening of the vagina (the introitus) two times a day for 12 weeks, tapering to once a day or less. Another option might be Intrarosa, a relatively new treatment for vulvovaginal atrophy, which I’ve begun using with some vulvodynia patients. Intrarosa is a vaginal insert, used nightly; it’s metabolized to testosterone (and estrogen) in the vagina, so I think this is going to help vulvodynia.

Note that vulvodynia can be difficult to diagnose, because the vulva and vagina may look normal. Describing your symptoms accurately will be extremely helpful!


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You say you’re considering pelletized subcutaneous testosterone as a response to flagging libido. I have seen good results with testosterone therapy, which you can read about in this blog post.

Testosterone, however, is one time that I never recommend pellets. It’s very difficult to manage levels and dosing in the pellet form, and I’ve seen plenty of awful outcomes of way-too-high doses, including masculinization that in some cases is irreversible (clitoral enlargement is one possible irreversible consequence, for instance).

While testosterone treatments are not FDA-approved for women in the U.S., we have plenty of data on transdermal, bioidentical testosterone use in women, and I think there is evidence those can be used safely if kept in female therapeutic ranges. I just don’t see pellets as allowing management in that safe therapeutic range. I use male pharmaceutical products at a fraction of the dose used for men.

Estrogen is fine in pellet form, but even there I rarely use pellets. We have such great bioidentical pharmaceutical products that are so much easier and flexible to use, with known, consistent dosing, which pellets just can’t provide. It’s hard to get too much estrogen delivered to women, in general. Although I have seen super-high levels with pellets, we don’t have information that this is harmful, and the only adverse side effect is usually breast soreness, which is reversible.

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Couple outdoors in springBuilding and maintaining intimacy takes time and dedication. It takes being attentive over the long haul. But many of the things that contribute to intimacy over time can also revitalize your relationship in the moment. Here are five things you can do right now—but that we hope you’ll do regularly—to make your relationship better.

  1. “Speak” your partner’s love language. According to Gary Chapman, author of The 5 Love Languages, there are five ways to express love: words of affirmation, acts of service, receiving gifts, quality time, and physical touch. It’s important to use your partner’s love language. While you may feel most loved when your partner spends time with you binge-watching your favorite show, he or she may feel most loved when you fix the problem with the router on the home network. Figure out your partner’s language, and then express your love by doing something in that love language.
  2. Say something positive. Years ago, two researchers did a longitudinal study of couples solving conflict. They found they could predict with 90-percent accuracy which couples would break up “based on the balance between positive and negative interactions during conflict…. For every negative interaction during conflict, a stable and happy marriage has five (or more) positive interactions”—inside jokes, teasing, or touching, for example. These so-called masters of marriage use positivity not only in moments of conflict but on daily basis to stabilize their marriage, and you can, too.
  3. Lighten up. Sing off key, dance La Macarena badly in the kitchen, or simply tell a joke or share an amusing anecdote from your shared history. (Be sure to choose one that’s entertaining to you both, and not one that’s humorous at your partner’s expense.) This time of life involves some emotional and physical hardship, so is it any wonder that we sometimes take it all too seriously? While we intuitively know that playfulness and shared laughter brings us closer to our beloved, research verifies that it really does. And not everyone has to think you’re funny—the only thing that matters is that your partner does.
  4. Check your cell phone at the door. Smartphones have become central to our lives, but their ability to distract us exacts a toll that we often overlook. In tests that measured cognition, people who completed task with phones on their desks (even when the phones were turned off) performed worse than people whose phones were in another room. The greatest gift you can give someone is your undivided attention. Leaving your phone in another room with the notifications off demonstrates to your partner that he or she has your undivided attention—and makes it easier to deliver on that promise.
  5. Celebrate a recent success, even something small. According to Tara Parker-Pope in her book, For Better, there’s a correlation between celebrating and increased trust, intimacy, and satisfaction in the relationship. So, whether your partner got a promotion, finished an online course, or had the courage to have a difficult conversation with a family member, get out a cheese platter and a pitcher of lemonade, and sit on the porch for a spell and savor the accomplishment together.

And here’s one extra thing you can do right now: Share this list with your partner—because you shouldn’t be the only one working at laying the groundwork for intimacy in your relationship.

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Re-engaging in intimacy is a bit different for each individual, just as everyone’s first experience of intercourse is unique. Some of the “preparation” can depend on the partner, the scenario, the amount of foreplay, and so on, so it’s a bit tough to know exactly when “you are ready.” I hope you can move into this slowly and gently to determine your readiness as you move forward.

An exam by your provider can tell a great deal. How comfortable was your last pelvic exam with speculum placement? I tell women that when I do a pelvic exam and place two fingertips into the vagina comfortably, it is quite likely they will be comfortable with intercourse. Because there are variations in male size and female elasticity, that may not always be 100 percent accurate.

Vaginal lubricantsYou say you’re taking vaginal estrogen, and that should be very helpful to your tissue health. This is a time using an intravaginal vibrator (like the Liv2 or Celesse) may be helpful. Can you insert and use these without discomfort? Having a good lubricant is very important as well. Most menopausal women benefit from a silicone or hybrid lubricant (and this article describes the variety of lubes and how you might select and use one). Some women need to use vaginal dilators to do some stretching of the vagina in advance of intercourse.

I’m so glad to hear you have found someone special to share intimacy!

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You say you’ve tested negative for herpes 1 and 2 antibodies, while your partner has tested positive for the herpes 2 virus, though he has not shown symptoms. I don’t find your situation unusual, and it does pose a bit of a conundrum. The reality is that using condoms is the most reliable way to prevent transmission, but in a long-term relationship, I understand that it’s not desirable.

I find that the most up to date and reliable information regarding HSV (and other STIs) is the Centers for Disease Control and Prevention (CDC), which is what I use to counsel patients:

  • HSV can be transmitted when lesions are not present.
  • Anyone with a HSV diagnosis is encouraged to inform current and future intimate partners, and to abstain from sex when lesions or their precursor symptoms are present.
  • Correct and consistent use of latex condoms might reduce the risk of transmission.
  • “Daily treatment with valacyclovir 500 mg decreases the rate of HSV-2 transmission in discordant, heterosexual couples in which the source partner has a history of genital HSV-2 infection. Such couples should be encouraged to consider suppressive antiviral therapy as part of a strategy to prevent transmission, in addition to consistent condom use and avoidance of sexual activity during recurrences. Episodic therapy does not reduce the risk for transmission and its use should be discouraged for this purpose among persons whose partners might be at risk for HSV-2 acquisition.”

What that last point means is that ongoing daily treatment with a prescription for an antiviral therapy by the affected partner can be effective protection to reduce the chances of transmission; “episodic therapy,” meaning the antiviral is taken only in cases of an outbreak of lesions, will not provide that protection.

I hope this is clear! You can have intimacy confidently, and I’m glad you’re researching the steps to take!

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Everyone likes nicely defined muscles, the kind that hint at strength and endurance and a healthy lifestyle. Some of us even work hard to build them. But what if I told you that exercising a certain set of muscles could not only help with the kind of bladder control that eludes many of us older women, but also lead to stronger orgasms and better sex in general? And that those exercises were fairly effortless and could be done anywhere?

You’ve probably already guessed that I’m referring to Kegels.

We’ve talked about these helpful pelvic floor exercises before:

  • Why do them. Strong, toned pelvic floor muscles are tremendously helpful in maintaining bladder control—a particular problem for older women—and in avoiding organ prolapse. Toned pelvic floor muscles also create a firm “vaginal embrace” during sex and can enhance your own orgasm.
  • How to do them. First, identify your pelvic floor muscles. These are the muscles you use to stop the flow of urine. If you’re still not sure where they are, insert a couple fingers in your vagina and tighten so that you feel the vaginal walls constrict. Now, contract and hold for five seconds; release for five seconds. Repeat ten times. Gradually increase until you can contract ten times for ten seconds.  Do these three times a day.
  • How not to do them: You are not tightening your belly, thigh, or butt muscles. Every other muscle should be soft. Do not hold your breath.

Let me just say that however you do Kegels (as long as you’re exercising the right muscles) is just fine. Sit, stand, lie. Make dinner or watch TV. Drive. Got the picture? Kegels are invisible to everyone but you. That’s the beauty of it. However, as with any exercise, Kegels aren’t a magic pill or quick fix. You may not notice improvement for weeks. The important thing is just do it! Regularly.

Let me also say that some women find using Kegel weights (also called yoni balls, ben-wa balls, vaginal cones) helpful in identifying and isolating their pelvic floor muscles. Weights may also help develop those muscles more intensively—like using weights to build your biceps.

With a dearth of solid research on the topic, you will find wild, and wildly diverse, opinions about using vaginal weights. The Kegel Queen swears that doing Kegels can cure everything from organ prolapse to bad sex. She would never consider using vaginal weights to augment them. On the other hand, Kim Anami, the Kung Fu Queen of vaginal weightlifting, says that most women aren’t helped by Kegels because they don’t do them properly. She, however, will teach you to move furniture, shoot ping pong balls, and lift weights with your vagina. Or control your partner’s ejaculation. This might terrify most men. Or not.

I’m thinking that the truth probably lies somewhere in between.

Luna Beads Vaginal WeightsWhile they’re not for every woman, vaginal weights add a level of gravitas to your commitment to Kegel. They come in a rainbow of sizes, shapes, and materials, from jade to silicone, balls to barbells. We’ve culled the selection to a manageable assortment in our shop. You can choose from a simple, inexpensive “starter” kit with two silicone balls to a programmable Elvie trainer that syncs with a phone or tablet app to customize your Kegel workout and give you biofeedback to make sure you’re doing them correctly. Then there are the classic Luna Beads, which are beautifully designed and easy to use.

To use Kegel balls:

  • Start with the lightest weight. Lubricate it well. (Don’t use a silicone lube with silicone balls.) Insert one just beyond your pelvic floor muscles, as you would a tampon.
  • While sitting, perform ten sets of Kegels—contracting, holding, and relaxing for five seconds each.
  • The next level is to practice standing with the weights in place. You have to maintain the contraction to keep them from falling out. Try to extend the length of time you can hold the balls.
  • If you’ve mastered standing, you can try holding the Kegel balls while squatting and then while walking around doing normal tasks. This level may be beyond most of us estrogen-depleted, “mature” gals.
  • Wash with soap and warm water. Dry and put away.

Kegels of any sort, weighted or not, are an important part of your downtown health regimen. They can help with bladder and bowel control; they can help keep your organs where they belong. Kegels improve muscle tone and blood flow to the pelvic floor, which makes sex more pleasurable for you and your partner. And if you decide to practice a little vaginal weightlifting, you can go here for inspiration.

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You say you passed the menopause mark (a year without menstruating) four years ago. You use a vaginal moisturizer every three days, and are successful with dilator use. Still, you have difficulty with “full and comfortable” intercourse with your husband.

You asked. Dr. Barb answered.I suggest that you take the largest dilator you’ve used in to your health care provider. Explain the situation, and have your provider insert the dilator and do a careful exam to see why there’s a discrepancy between success with the dilator but not with intercourse.

The term “hitting a wall” is most often used with the diagnosis of vaginismus. Vaginismus is involuntary spasm (tightness or tautness) of the pelvic floor muscles. Because this is involuntary, you can’t “just relax” the muscles.

This is a clinical diagnosis that can often be treated with dilators, but may also need pelvic floor physical therapy treatment as well. Your provider will be able to help in that determination and then to direct to you a physical therapist with pelvic floor expertise.

Good luck! It’s worth pursuing to regain that intimacy!

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