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Our friends at The National Association for Continence recently reported that fully 40 percent of women are doing Kegel exercises incorrectly.

Oh dear.

We want to do our part to correct that, because for one thing, it’s not really that hard to do them right. But most especially because, you really can’t do a single solitary thing to help you maintain pelvic health throughout your life that is more beneficial than Kegels. To avoid incontinence, pelvic organ prolapse, uncomfortable sex, urinary tract infections, a host of difficulties as we age.

Not. One. Thing.

And that goes for your mom. And your daughter.

And guess what? For any man in your life, too.

Yeah! Everybody!

Everybody! Do the Kegels!

But, well, we have a focus here at MiddlesexMD, so our links and discussion might be a bit more female-anatomy-ish. But here’s a very specific link for the men, just so you know I’m quite bullish about Kegels for men, too.

Okay. Let’s get our Kegels on.

First, if you need a refresher, on your the pelvic floor muscles, I wrote all about that here. I encourage you to review that post so you can envision the lovely figure-eight sling of muscles that hold all of your important organs in their proper places, happily chugging along as you move through your busy day.

Once you have a clear sense of that pelvic sling of yours, find a place to sit quietly, feet on the floor, straight out from your hips, hands just folded quietly in your lap, eyes closed, breathing softly, with the space and time to give this practice a little focus.

Are you there? Good. Now, as if you were stopping the flow of urine mid-stream, tighten the muscles around your vagina. That’s all, just as if you were stopping the flow.

And there they are! Those are the primary muscles we will be working!  Well done, you!

Let’s take it another step. Working just a little harder, imagine that you are sucking a heavy, marble ball into your vagina. But, let’s make it a warm one, and well lubricated!

As you develop your sense of your inner landscape, try tightening your inner pelvic muscles to draw your pubic bones and tailbone together or imagine trying to draw your “sit bones” toward one another.

But! And here is where things can go wrong, and where people tend to run off the tracks. When you are doing your Kegels, you should not be tightening your buttocks. Let those stay relaxed. Don’t tighten your inner thigh muscles, either. Let those stay soft.

Definitely don’t hold your breath. Breathe softly. Do not suck in your gut. All is soft except that sling under your organs. Focus. And breathe. This thing that takes some concentration at first will become so natural with practice you will be able to do it while waiting in line at the grocery store.

Here are further ways you can help yourself really refine your practice, and I love these recommendations, and very much encourage you to actually do them!

First, get up close and personal. Use a hand mirror and a good light to watch what happens when you contract these muscles. That’s right—look in the mirror at your pelvic floor in action. It’s pretty cool to see what you can do when you are working those muscles!

Second. Remember they are muscles, and like all muscles, they have a full range of motion that should be worked. Most of us do our Kegels just contracting them. But it’s good practice also to stretch, or elongate them. And one of the best ways to think about that is the Elevator visualization. It goes like this:

Think of your relaxed pelvic muscles as the first floor. Contracting your Kegels as we did for the urine-stop visualization is like taking them to the second or third floor. The marble sucking exercise is maybe the fourth floor. And if you use actual Kegel weights or barbells you can go to the higher floors still. But elongating, or stretching the muscles, is taking your pelvic floor to the basement. Something that’s very good for them. Elongation tends to happen naturally when you yawn. But it’s a nice thing to do for them at the beginning and end of your Kegel sessions. Stretching is a kind of pushing action, a little bit of a bearing down, to stretch the connecting ligaments a little bit, get the blood flowing.

So, I hope that clears thing up. Don’t be among the 40 percent. And don’t let anyone you love be, either. Good pelvic health is everyone’s right. We ought to be the generation that ensures this for everyone.

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You say you can hold one bead, but not two. The only thing you’re doing wrong is expecting too much too soon! It takes time to increase muscle strength, and if you only recently bought the weights, you likely only need more time.

Start by using the weights for a few minutes while sitting; go to standing as you’re able. You can also increase the time as you’re able, and if you’re using Luna Beads, you can increase the weight, too, by interchanging beads. Each step can take weeks, and not everyone can build enough strength to get to the maximum weight.

If you’ve had surgery or radiation, your vagina may be too short to hold both beads. If vaginal depth is causing problems for you, dilator therapy, which also requires patience, can help to restore capacity.

Take your time, grant yourself patience, and stick with it!

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Like you, I feel the pull of the New Year, the impulse to fresh determination and resolve. (It partly comes, I think, from the satisfaction of packing away the Christmas decorations—much as I love them during the holidays!) I see the January magazine covers with headlines that offer a more organized, less stressed, healthier life.

And I see evidence of the season in the order trends here at MiddlesexMD. There are clearly a number of us who are making resolutions, and our fresh-start, new-focus impulse includes our sexual health.

As we’ve said before, being specific helps when making resolutions. So I dug into the data to see what other women have been choosing during this season of self-improvement. Here are the most popular choices, consistent over the past three years, and the reasons why I’d guess they land at the top of the list:

Vaginal moisturizer: I love that this lands at the top of the list. Moisturizers are used regularly (we put lotion on other body parts daily!) to strengthen vaginal tissues and keep them healthy. They supplement the moisture that we lose as our estrogen levels decline. Yes Water-Based moisturizer is our most popular, but we offer other options as well, including a subscription that keeps you stocked.

Lubricant: Lubricants are the very easiest defense against uncomfortable sex, which many of us experience with vaginal dryness. The most popular resolution purchase is the Personal Lubricant Selection Kit, and for good reason, I think. With the kit, you can sample seven different varieties, and then receive a full-size bottle of your favorite. If lubricants are new to you, this is especially helpful: The drugstore options are overwhelming, and I hate to buy a full-size bottle of something I end up not liking! All of our lubricants are selected for safety, efficacy, and fit for the needs of midlife women.

Kegel tools: I’m also happy to see these among the most-purchased at this time of year. Our upper arms are more visible, so we get a visual prompt to add them to our tone-up list. Our pelvic floors are out of sight and often out of mind—until we’ve lost enough muscle tone to experience incontinence or diminished orgasm. Strong pelvic floors do so much for us! And Kegel tools help us focus on the right muscles to flex, as well as reminding us to do those pesky flexes. Luna Beads Vaginal Weights are among the products most purchased at this time of year (and are actually the most popular of our Kegel tools throughout the year).

Just because these have been popular, of course, doesn’t mean they’re right for you; take some time to think about your own starting point and priorities. But you can also take some comfort in knowing there are simple steps you can take, and you’re not alone in the journey!

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We know about muscles. We use them; maybe we tone them; maybe we watch them get saggy over the years.

But the vagina?

Yep. That too.

Our pelvic floor is encased in muscle. And just like all the rest of our muscles, it needs regular exercise, especially as we grow older. Age, childbirth, and loss of estrogen take their toll on all that musculature. Like everything else in our anatomy, it ain’t what it used to be.

We’ve talked about the importance of vaginal exercise before—in the form of kegels. That clenching-and-holding of the pelvic floor muscles helps keep our pelvic floor muscles toned, which in turn keeps us continent, keeps our abdominal organs in place, and creates a firm “vaginal embrace” that our partners ought to find very, um, invigorating.

What many of us don’t know is that a handy exercise tool exists to help us tone our pelvic floor. We call them vaginal weights. (A similar version is called ben wa balls, which is an ancient Eastern sex toy that uses weighted balls of various materials. These are said to be mildly stimulating.)

Ana of Fifty Shades renown tucked these little numbers into her vagina for a hot date with Christian and “wore” them throughout the evening. This is a tricky maneuver, requiring good muscle tone and constant attention. Stand up without clenching those pelvic muscles, and you’ll lose your balls, so to speak.

I’m thinking that, by the end of the evening, Ana may have experienced some fatigue “downtown,” but, what with rocks in her sock, she surely was reminded at every turn about where the evening was headed.

In the MiddlesexMD store you’ll find our Luna Beads—four interchangeable balls that allow you to increase the weight you’re carrying. You could try to imitate Ana’s trick on your next date night, but I’d suggest trying them out at home until you’re confident you can keep the things where they belong. Your muscles will thank you, and your partner may, too.

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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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*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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Whether you were already menopausal or were abruptly deposited into menopause after treatment for your cancer, you’re probably familiar with what happens to your vagina when you lose estrogen.

You may experience the burning, itching pain of thin, dry vaginal walls and fragile skin on your genitals. You don’t lubricate like you used to, so sex can be difficult or painful. Or, if you’re experiencing the muscle spasms of vaginismus, sex may be impossible. Less estrogen is a good thing for some cancer treatments, but it’s darned tough on the vagina and, by extension, on your sex life as well.

So, while vaginal health is important for all women during menopause, it’s critical for those undergoing cancer treatment. Your vagina and pelvic floor need a lot of TLC right now to stay comfortable and responsive. Fortunately, compared to the other things going on in your life, taking care of your bottom is usually straightforward and inexpensive. Besides, keeping your vagina in good shape might eliminate one problem area and allow you to stay in touch with your sexual self, too.

Consider this four-part approach to caring for your vagina and pelvic floor.

First, use vaginal moisturizers and lubricants.

Moisturizers are your first line of defense. These are non-hormonal, over-the-counter products that are intended to keep your vagina hydrated and to restore a more natural pH balance. They should be used two or three times a week, just as you’d moisturize any other part of your body. Replens, Yes, and Emerita are examples of moisturizers.

Using moisturizers is important whether or not you’re having intercourse. It should just be part of a regular health maintenance regimen.

Use lubricants liberally before intercourse, on sex toys such as vibrators, and any time you touch the delicate tissue on your genitalia. Also apply lubricant to your partner’s penis.

At this point, keep your lubricants plain and simple—no scents or flavors; avoid warming lubes. Don’t use any product with glycerin, which can create an environment conducive to yeast infections, and don’t use petroleum-based lubricants.

Second, keep your pelvic floor toned. “The pelvic floor is really important in keeping your internal organs in place, preventing incontinence, and enhancing sexual pleasure,” says Maureen Ryan, nurse practitioner and sex therapist.

Plus, knowing how to relax your pelvic floor muscles is helpful if you’re experiencing the involuntarily spasms of vaginismus.

Kegel exercises, in which you flex and relax the muscles around your vagina, will tone the pelvic floor. Or, you can purchase exercise tools to tone your pelvic floor muscles. This is a great way to make sure you’re exercising the right muscles.

Third, use dilators if your vaginal capacity is compromised. Dilators are cylinders that come in sets with various sizes. They’re meant to gradually increase the size and capacity of the vaginal opening, which can be important, especially after some cancer surgeries and treatments that constrict the vaginal opening or create scars and adhesions.

To some extent, dilators are helpful just to reassure you that you can tolerate something in your vagina again.

Start with the smallest size dilator, lubricate it, and gently insert it as far in as you can tolerate. Try doing kegel exercises, tensing and relaxing your pelvic floor muscles. Can you feel your muscles close around the dilator? Keep it in for maybe ten minutes and repeat this exercise several times a week. Move on to the next largest size when you can tolerate it.

Fourth, use a vibrator (lubricated, of course). Self-stimulation increases blood flow to your genitals and helps reacquaint you with the feelings and sensations of your body. The more stimulation you can bring to the area, the healthier it will be.

The point is to keep the vulvo-vaginal area moist and flexible, to increase blood flow, to stay responsive, to maintain capacity, so that when you and your honey are ready to start your engines, you’ll both enjoy a smooth ride.

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