When I think about how easy it has been for society to marginalize the aging vagina, I can almost believe that God really is a man! However, with so many women-centric advancements taking root, many of which have sprung up from the #MeToo movement, I’m finding that women’s sexual health is finally taking a front—if not exactly center—seat in the spotlight. If I may, I’d like to take that spotlight and shine it a little closer to the issue of sexual health for women over fifty. “Older vaginas” are still in need of a voice—so to speak—and I’m here to give it to them, as are a number of other qualified and enthusiastic physicians and educators, one of which is Dr. Sheryl Kingsberg.
As president of the North American Menopause Society (NAMS)—yes, there really is a national menopause society—Dr. Kingsberg has said, “With the recognition that women have a right to their sexual health, it’s important to make our membership [referring to other OB-GYNs] comfortable with the dialogue about it.” She and many other health professionals are aware of what a difficult time older women have in talking about their sexual health, especially as it relates to the vagina. Although vaginal dryness, painful sex, and inability to orgasm are some of the key issues for women over fifty, those are the very issues that women and their doctors seem most uncomfortable talking about. Look, doctors are people—and they are certainly not mind readers—which often means that they are as uncomfortable as their female patients in having the mature sex talk. The sad fact remains that 40 percent of women do not share sexually related problems with their health-care providers. And since those providers do not open up the conversations in the first place, so much pertinent information about sexual dysfunction goes unsaid.
In her attempts to re-educate OB-GYNs and other health-care providers, Dr. Kingsberg has nailed the definition of sexual dysfunction as a “loss of wanting to want.” This simple re-defining of the term “sexual dysfunction” helps guide treatment in the direction of “focusing on the desire for desire as much as achieving sexual satisfaction,” which is key for treating women—especially since women’s sexual desire, unlike men’s, tends to begin in that great organ above the shoulders, not below the waist.
Given that women’s sexual desire starts in the brain, it’s not surprising that hypoactivesexual desire disorder (HSDD)—which refers to the absence of sexual desire—is not only the most common form of female sexual dysfunction, it is also one of the most complicated, most undetected, under discussed, and untreated! For the onethird of the female populationthatsuffer from HSDD, factors may vary, but the frustration and pain of those factors form a common thread. And, unlike the fact that there are twenty-six approved medications for male erectile dysfunction, there aretwo for women—by the way, the one FDA approved medication for HSDD is approved for women to use in pre-menopause, leaving all menopausal women with very few treatment options. That said, I hope to bring awareness to what I refer to as The Collapsed V.
Case in point: My patient, Laura B., a vital (menopausal) fifty-five-year-old clothing designer and stylist, jets all over the globe for her international clients. No one could even begin to guess her correct age just by looking at her, and I defy anyone to believe that she is in menopause. But the fact is, despite a loving relationship with her husband of many years, Laura came to me after four months of avoiding intercourse. Aside from extreme vaginal dryness, she had been experiencing vaginal swelling and symptoms of a bladder infection after sex. She would feel the urgency to pee and a pressure upon urination. We ruled out infection, and then, a week later, after having intercourse for the first time in four months, an exam revealed that her visibly irritated vagina had evidence of superficial tearing. She said to me, “I feel like I’m losing my virginity every time I have sex now!”
I coined The Collapsed V in order to classify a problem that I see every day in my practice, a problem that the medical world has been slow to acknowledge and slower still to address with any real solutions.
For women in menopause, the most common complaint (cry) I hear is dryness in the vagina. Unfortunately, dryness isn’t just a problem for menopausal women; it affects women with breast cancer and those who are undergoing treatment for other types of cancer as well as women who have infrequent vaginal intercourse. As a matter of fact, a thirty-four-year-old patient of mine—because of her husband’s chronic illness and inability to have an erection without a little blue pill—only has sex a few times a year. And, even though her relationship with her husband has been emotionally satisfying (and they’ve been creative in their physical connection), her vagina has suffered from “inactivity.” She, too, has what I refer to as a Collapsed V.
Despite the fact that you may feel comfortable talking to your OB-GYN or your girlfriends about sex, you may hesitate to bring up your dehydrated or inactive vagina. But you ought not suffer in silence. The Collapsed V is a problem that is all too common, one that we need to talk about and find solutions for, if we are to experience sexual intimacy beyond menopause or illness or infrequent romantic encounters. First, it’s important to figure out the cause of your Collapsed V, which, in many cases, has to do with the “M” word.
Ah, yes, menopause—the great equalizer of women. Finally accepted your AARP card? Congrats. But what might be even more helpful than discounted movie tickets is a better understanding of the sobering statistics of menopause and how it affects your vagina.
• Menopause makes everything on your body dry—your eyes, hair, mouth, skin, and especially your vagina. The vagina also becomes more narrow, shorter, less flexible and smaller at the opening.
• There are 64 million postmenopausal women in the US, of which at least 50 percent suffer from vulvovaginal atrophy, now known as Genitourinary Syndrome of Menopause (GSM).
• GSM is under-diagnosed and undertreated.
• The two most common symptoms of GSM include pain with sexual penetration and vaginal dryness.
• Painful intercourse, medically known as dyspareunia, is not covered by insurance. Absurdly enough,while erectile dysfunction is considered by insurance companies to be a medical condition, dyspareunia it’s considered a “lifestyle issue,”and is therefore not covered by most medical insurance.
• Only 7 percent of women are taking prescription medication to treat GSM.
• Out-of-pocket costs, lack of symptom improvement and concerns about long-term estrogen exposure of the estrogen medication frequently prescribed for GSM, discourage women from being consistent with treatment.
• Estrogen patches—often used as treatment for GSM—may cost as much as 150 dollars, whereas testosterone patch treatment for men usually runs around two dollars.
• “Health care providers do not pay attention to midlife sexuality or female sexuality in general,” states Dr. Sheryl Kingsberg, president of the North American Menopause Society (NAMS).
• Women are not being educated that their GSM symptoms are related to menopause.
Treatment for GSM must include ways to make the vagina less dry and the vaginal opening less narrow. Initially, doctors need to be doing a much better job of discussing the symptoms of GSM their patients and how it may impact their sexual relationships.
The bottom line is that menopause can be f%$*ing brutal on the vagina. With your new normal of hot flashes and weight gain, irritability, mood swings, heart palpitations, and insomnia, it seems unfair that you would also have to deal with a new state of your vagina, especially since vaginal dryness becomes most apparent after you’ve begun to weather all the other effects of menopause. If you’ve opted out of any type of estrogen therapy, vaginal dryness usually becomes most disruptive around the fourth or fifth year after the onset of menopause, which means that any type of vaginal penetration, either with a penis, fingers,vibrator, or dildo may cause pain. However, your vagina does not have to give in to the hormonal disadvantages that come with menopause and a lack of estrogen. There are ways to help the vagina to retain its elasticity and pliability in order to avoid pain and discomfort with sex.
Breast and other Female Cancers
Many women become fixated on the statistic of “one in eight women are diagnosed with cancer.” For many, the question isn’t “if”—it’s “when” will I contract that disease? For the majority of those women who are diagnosed with breast or other female cancers, sexual dysfunction will go hand in hand with a diagnosis.
Since estrogen is often an enemy to breast and other female cancers, part of a treatment plan may involve medications to stop estrogen production, which sets the stage for worsening vaginal dryness and a decreased interest in sex all together. Although it stands to reason that sex may not be high on a list of “to dos” for a woman battling cancer, physical intimacy can play an important part in maintaining one’s sense of self. Unfortunately, and all too often, a woman who misses her sexual self may feel uncomfortable or selfish in discussing that particular loss, especially with the oncologist who is trying to save her life. For her, sexual intimacy becomes the elephant in the room.
The oncologist who sees his or her patient weekly may rarely bring up the topic of intimacy and sex, and therein lies part of the problem. No one is comfortable talking about sexual dysfunction as a byproduct of illness. In fact, The Lance Armstrong Foundation found that only 13 percent of women going through cancer treatment discussed their sexual dysfunction with their health-care provider. Ideally, cancer treatment should involve someone with the proper training in sexual dysfunction—a psychologist or a sex therapist—that can deal with a patient’s sexual health. As I discussed further in The Pink V chapter in my first book, there are many landmines women suffering from breast and other female cancers experience as they embrace their role as cancer survivor—or cancer thriver.
Cancer can be a triple whammy as it is also accompanied by the loss of sexual intimacy and sexual penetration with one’s partner—all ingredients for a Collapsing V.
Infrequent Sexual Penetration
Literally, “if you don’t use it, you’ll lose it!” Over time, with disuse—meaning that you don’t use your vagina for sexual pleasure—your vaginal opening will become smaller and smaller. Now, of course, it will never close up completely, but shrinkage or collapse will occur. Eventually, you may completely disassociate or divorce yourself from your vagina altogether. You may talk yourself into believing you really don’t want to have sex or penetration, or you may find yourself saying, “Cuddling is all that matters for a woman my age.” Well, the woman who said that to me was only sixty-two. Frankly, I was surprised that she’d given up on her vagina and her desire to enjoy sex with her longtime partner.
If you take into consideration that the average life span for a woman is around eighty years, sixty-two seems awfully early to be retiring your vagina. Don’t you think?
In fact, as long as we’re talking “retirement,” I feel like I ought to bring up the vagina that has been in perpetual retirement, and by that I mean the “virgin” vagina, a vagina that has never been penetrated with a penis or dildo. First off, I’d like to say: It’s never too late. And if you are starting late, or starting early, or coming out of “retirement,” please consider a vaginal dilator, as it will definitely make a world of difference.
When you have sexual intercourse for the first time (or you’re penetrating your vagina with a dildo or even a finger for the first time) it is common and completely normal to experience some degree of pain, discomfort, and bleeding, which is why using a vaginal dilator is a good way of readying yourself. I don’t know any “first timer” who hasn’t thought, “How much pain will I experience my first time?” or “When will I stop bleeding?” or “How long will it take for sex to actually feel good?” To that end, I’ve always wondered, “Who decided that this “first time” female rite of passage should involve so much pain?”
Even the term “popping the cherry” sounds daunting. For starters, it can be helpful to understand that this term refers to the breaking of a woman’s hymenal ring, the thin, circular or crescent shaped fold of mucous membrane over the vaginal opening, which varies in shape and size from woman to woman. This hymenal ring is the “cherry,” and although it is broken with sexual intercourse, it can also break with recurrent tampon use, exercise, masturbation, or fingers. In other words, you can be the first to pop your own cherry, if you so desire!
As discussed in the TLC V chapter, Vaginismus is a condition in which the muscles of the vagina contract, tighten, or spasm involuntarily, causing vaginal pain, sexual discomfort, burning, and penetration problems. One commonly experiences symptoms on an ongoing basis—during sexual intercourse, inserting a tampon, and during a pelvic examination—resulting in a disruption of intimacy, personal relationships, and daily life activities. Vaginismus is both emotionally challenging and physically painful, especially when even the most basic of habits, such as tampon use is cause for anxiety and fear. It has ruined relationships and self-esteem, and claimed responsibility for sexless, unconsummated marriages.
But there is no longer a reason for any woman to suffer in silence from a Collapsed V caused by this condition or any other, for that matter. There are better ways!
Clitoris: Out Of Service
Unfortunately, collateral damage of a Collapsing V can often include what I would describe as an “out of service” clitoris—medically referred to as acquired orgasmic dysfunction (AOD).
If you’re finding it harder and harder to have an orgasm in menopause, it may be because your clitoris is no longer taking the hint. Physiologically, it makes sense, especially when you consider how helpful estrogen is in achieving orgasm. When the ovaries stop producing estrogen this translates in less blood flow to the vulva, clitoris, and vagina, causing the entire area to become thinner, drier and more delicate. A combination of menopause and other medical conditions such as diabetes andside effects of certain medications makes having an orgasm that much harder, if not impossible.
Treatment for the Collapsing V
It took months, if not years, for your vagina to join the ranks of Collapsed V, so, in order to restore it, to make it vital and elastic again, you must dedicate yourself to new routines and habits that may take anywhere from a few weeks to a few months in order to see results. You must embrace a new normal in feminine rituals. These new routines may feel as welcome as calculus homework, at first, but your Collapsing V will ultimately benefit from those treatment routines—which may include hydration/moisturizing, dilation, physical therapy, and HRT (hormone replacement therapy), or some combination thereof.
First order in avoiding pain in vaginal penetration is to begin with a moist vagina.
You may remember a time when just the thought of intimacy and sex made you “wet.” Imagination and anticipation may have been all you needed, and it may have worked great in your twenties and thirties, but, with life and all the complications that come with growing older, getting wet is probably not as easy as it used to be.
Chances are that, if you’re nearing (or over) fifty, unless you have the proper foreplay to become sexually aroused, “getting wet” may, sadly, be impossible. If the vagina does not get wet, it means that it isn’t producing a natural lubricant, the result of which is dry, painful vaginal sex. Also, the friction of sexual contact and penetration can cause the natural vaginal lubricants to dry up. Ultimately, this may be due to a drop in estrogen, caused by—you guessed it—menopause.
In fact, the two main hormonal assaults on the body that result in a drop in estrogen—and lead to a dry vagina—are menopause and breastfeeding. Of course, breastfeeding occurs during your reproductive years, while menopause typically happens at around age fifty. But the good news is that both of these hormonal conditions leading to vaginal dryness are reversible. Once you stop breastfeeding, the vagina will return to its normal healthy and hydrated state. However, dryness in menopause may be remedied with a variety of treatments, including vaginal estrogen, DHEA, hyaluronic acid, HRT, over-the-counter lubricants, vaginal suppositories, and laser treatment.
Additionally, the Mona Lisa Laser treatment—a treatment similar to facial micro-abrasion in that it removes dead cells, and increases blood flow and collagen production inside the vagina—has been proven successful in battling dryness. Three painless 3-minute sessions just six weeks apart and yearly thereafter seem to do the trick. In between treatments, vFit, a home-use intimate wellness device using red light therapy, can help to promote blood flow and natural vaginal lubrication by improving pelvic floor tissue and muscles. Together, Mona Lisa and vFit make a great team in combatting vaginal dryness and getting your vagina back in shape! For those not ready for Mona Lisa, vFit is a great start
Dilators to the Rescue!
Also referred to as expanders, dilators should be part of any conversation with your health-care provider in combating a Collapsed V. Relatively new in the arsenal to battle vaginal dryness, dilators have been lauded as a welcome and effective treatment as they can re-train, expand, and gently stretch the entrance and canal of the vagina.
If you’re trying this method, it’s recommended to use a set of vaginal dilators varying in sizes and thickness, from small to large—soft silicone dilators are the most comfortable and work best with the vagina as they minimize vaginal infections and tearing. The trick is to start with the smallest size and leave it inside the vagina for five to twenty minutes, two to four times a week. Duration of therapy is individualized for each woman, depending on the cause and circumstances of dryness. Best to use a comfortable lubricant or extra virgin coconut oil as you insert the dilator while lying on your back with your knees bent. In fact, a well-lubricated dilator and vagina is a must! Performing Kegel exercises at the same time as insertion is thought to help relax the pelvic floor muscles and make the process easier.
Your gynecologist can show you how to use your dilators correctly, but it is up to you to control the frequency of use and the speed in which you advance to larger-sized dilators. Relaxation exercises and physical therapy can also play an important part in dilator therapy, helping to make the process a success.
Up until now, dilators were designed for use only while lying down. Unfortunately, that did not bear well for the multi-tasking women of today who need to do the dishes or read bedtime stories to their kids while doing dilator therapy. With that in mind, I designed wearable dilators to be used while standing and multi-tasking. (No, I haven’t thought of everything, but I’m trying.)
Since the biggest problem with effective dilator treatment has always been poor compliance, I’m hoping women will turn to this new and improved model to help themselves.
PT (Physical Therapy) for the Vagina
As easy as it is to relate to PT for back or knee pain, PT for the vagina and bladder may sound a bit foreign to most women, but it turns out that PT for pelvic issues is growing in acceptance and popularity as a last resort in resolving issues related to painful sex and bladder dysfunction.
In fact, there are physical therapists trained in exactly this field. These qualified therapists will meet with you in order to get a clear understanding of the nature of your symptoms and then follow up with a pelvic exam in order to identify areas of weakness in and around the vagina. The therapy itself usually involves weekly sessions of stretching and massaging the outer and inner vagina in order to treat the areas of discomfort.
As with any other health professionals, you may get a referral for a vaginal physical therapist from a trusted health care provider or from your gynecologist. You may even find that your gynecologist is trained in just this sort of therapy. You won’t know until you ask.
Hormone Replacement Therapy (HRT)
There has been a decided rush to judgment in recent years as to whether or not HRT is helpful or hurtful in the long run. In fact, the landmark Women’s Health Initiative Study (WHI) in 2002, which examined hormone replacement therapy (HRT) and its impact on breast cancer, heart disease, and osteoporosis has been the biggest deterrent to women considering estrogen replacement therapy. The study’s conclusions caused enough panic among women so that HRT became a dirty word. Truth is that the findings were inconclusive in many ways, as results varied depending upon the health of individual women. Subsequently, it was concluded, “Hormone therapy affects many organ systems in the body and changes the risks of many diseases—some in good ways, others in bad ways. Depending on hysterectomy status, age, and other individual factors, the consequences can vary dramatically.”
What is now understood is that HRT is safe for many women to use within the ten-year period of time from the onset of menopause. The bottom line is that menopausal women need personalized care in their treatment, not information from generalized studies. Their vaginas depend on it!
Vibrators: Still a Girl’s Best Friend
In addition to the varied treatments for a dry vagina (or out of commission clitoris), I always suggest trying a vibrator. Especially in the case of acquired orgasmic dysfunction (AOD), which I talked about earlier, a vibrator can be an easy solution in helping to achieve orgasm when the aging process seems like it’s arm wrestling you in the bedroom.
I would love to normalize the conversation about the usefulness of vibrators in treating orgasmic dysfunction, since not only do orgasms ease the stress of every day living, orgasms work out the pelvic floor—which helps with incontinence. In addition, they are good for the heart, the mind, and the soul.
Do yourself a favor and give yourself the gift of my favorite vibrator, the Inspire Vibrating Ultimate Wand by Caloxotics. (Amazon Prime can get it to your nightstand by tomorrow morning!)
The unfortunate fact is that many women will suffer from painful sex for years before broaching the subject with a health-care provider. It’s been reported that “30 percent of women experience pain with vaginal sex and most don’t tell their partners when sex hurts.” Don’t wait, please. Aside from the common issues I’ve mentioned, there are many other diagnosable and treatable causes of a vagina that feels like it’s collapsing under pain! Those causes include:
• Vaginal Infection. The signs and symptoms of a vaginal infection may include vaginal discharge, odor, or itching, which may be the cause of your vaginal pain and swelling with sex. A trip to your health-care provider will keep you educated.
• Pelvic Inflammatory Disease (PID). Sexually transmitted infections (STIs) such as Chlamydia and Gonorrhea are the typical culprits of PID, a serious pelvic infection that can lead to infertility and pelvic pain. Getting STI checkups is especially important when you change sexual partners.
• Penis Size. “Bigger is better” is not the case for a vagina that can’t tolerate a long, thick penis. The average penis is 5.7 inches in length and 4.8inches in diameter (girth). When flaccid (not erect) the average penis measures between three and five inches. When erect, the average penis measures between five and seven inches. The vagina may stretch to accommodate a larger sized penis, but it may take time, patience,strategic sexual positions, vaginal dilators, and open communication.
• Vaginal Tears and Lacerations. Tears and lacerations can result from many things—sex without proper lubricant, a larger-than-average penis, use of a particular sex toy, or trauma from childbirth. Vaginal lubricants can help avoid some of these problems.
• Latex Allergy. The majority of condoms are made out of latex, which propose little problem to most women, except those with latex allergies. An allergic reaction to latex may involve vaginal swelling, itching, and pain during and up to thirty-six hours after sex. If you have a latex allergy, you can use a polyurethane condom as an alternative for your safe sex measures.
• Ruptured Ovarian Cyst. If you are having sex during ovulation or mid-cycle, chances are there is an expected large ovarian cyst waiting to ovulate and release the egg. Aggressive sex can cause this cyst to rupture, releasing its fluid contents along with the egg and causing pain. A pelvic ultrasound combined with your menstrual history can help with a proper diagnosis.
• Endometriosis and Uterine Fibroids. Both of these female problems can cause pain with sex, especially with deep penetration. A detailed health history, pelvic ultrasound and a discussion with your health-care provider of other related symptoms are necessary in order to detect these conditions.
• Positional Sex. Certain sexual positions are known to be anatomically hard on the vagina and female organs, including the uterus and ovaries. The missionary position tends to be anatomically easier for women, whereas Doggie Style or “from behind,” which allows for deeper penetration for the male, may bring more discomfort and pain for many women.
• Virginal. If you have never had vaginal penetration with a penis, your first experience with sex will probably be painful. It may take time and regular sex before you start to experience anything like pleasure. Prepping the hymenal ring with a vaginal dilator a month before penetration would be a novel and effective plan. Also, a good lubricant or numbing gel (lidocaine) at the entrance of the vagina can also help relieve pain.In any case, patience and good communication with your partner is the right recipe for success.
• Emotional Problems. Depression, anxiety, relationship problems, and fear of intimacy all play a role in painful sex. Psychotherapy and the ability to communicate your feelings to your partner can help overcome some of the emotional problems that may inhibit a healthy, enjoyable sex life.
• History of Sexual Abuse. Any history of sexual abuse and trauma (emotional or physical) can contribute to an aversion or general dislike of sex. A devastating experience that leads to “post-traumatic stress disorder” may only enable you to feel pain with sex. As in dealing with emotional problems, therapy and open communication with your partner is key to helping resolve issues linked to abuse and trauma.
When it comes to dealing with the cause, effect, and treatment of a Collapsed V, women simply want the same responsiveness from the medical community as men have had with their sexual issues.
Think about this: A man walks into his doctor’s office with a complaint about his inability to have or maintain an erection, and then he walks out with a little blue pill. Boom. A woman walks into the same doctor’s office with a complaint of period pain and pain with sex. If the underlying cause of that pain is endometriosis, it will take, on average, 9.2 years for that woman to be correctly diagnosed, as reported in Lili Loofbourow’s illuminating 2018 essay, “The female price of male pleasure.”
In that same essay, Loofbourow noted that PubMed (the database for the National Center for Biotechnology Information) has 393 clinical trials studying female dyspareunia—the severe physical pain experienced during sex—10 clinical trials studying vaginismus, 43 studying vulvodynia, and 1,954 devoted to the study of erectile dysfunction. Here’s the math: There are five times as many clinical trials on male sexual pleasure as on female sexual pain. Women are the ones who forego the conversation on their own sexual health and experiences, since society seems to be telling them that the ultimate goal of the sexual experience is a man’s orgasm. That is not an ultimate goal. The goal needs to be an equally shared and equally satisfying experience, one that is pain-free.
It is time for women not to feel shame or embarrassment about issues of their own sexual dysfunction. In fact, the FDA is finally showing support for the challenges faced in female sexual health by researching and approving viable new treatment options. There are health providers out there who are willing to listen and act, and there are treatment options available—even if they don’t come in the form of aneasy-to-swallow, little blue pill. As women, our needs are a bit more complicated than that—to which I say, “Amen.”