Collapsed V

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. | | | Next → |

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