Many women in our age group write
me that they’re experiencing pain with sex or avoiding sex because of pain. I
consulted several experts for their advice in chapter 11 of Naked at Our Age: “When Sex Hurts:
Vulvar/Vaginal Pain,” but reading that chapter is just the beginning of solving
that problem. You need a diagnosis – vaginal/vulvar pain can be caused by a
number of medical issues, and you need to understand why you’re having pain
before you can get it treated effectively.
receive a review copy of Healing Painful Sex: A Woman’s Guide to Confronting, Diagnosing, and Treating Sexual Pain
by Deborah Coady, MD and Nancy Fish, MSW, MPH. This book is entirely
devoted to sexual pain in women: the myriad possible causes, how to figure out
which one or combination is yours, and what to do about it.
power team: Deborah Coady is a gynecologist and a pelvic/vulvar pain
specialist. Nancy Fish is a therapist with degrees in social work and public
health, and she personally experienced chronic pelvic pain until Dr. Coady
helped her resolve it.
answer some questions that women our age often ask me:
Q. Many older women are reluctant to ask
their gynecologists about sexual pain because a) they’re embarrassed, b) they
think this is part of aging, and c) they fear their doctors will be dismissive.
What would you say to these women?
A: These feelings and fears are completely understandable. Unfortunately, the
medical profession has until now given too little attention to the sexual
concerns of women as we get older. Women often are dismissed or rushed when
they bring up their problems. And this is not the fault of the patients: A
recent survey of gynecologists by Stacey Lindau, MD of the University of
Chicago hints to their discomfort, as well as their lack of experience and
formal training in this area of medicine. While 60% responded that they
did ask about sexual problems at the first visit, only 14% asked about pleasure
with sexual activity. It is often up to women themselves to be pro-active, ask
the hard questions, and remember that they are entitled to medical therapy for
this medical problem, or referral to an MD who can help.
Q. My readers sometimes report that after
a long time without sex (due to lack of a partner or disinterest from a
partner), they try to have sex again — and they can’t: It’s too painful. What
should a woman do about this?
A: On average, about 5-6 years after their last menses, most women develop
thinning of their vulvar and vaginal tissues, often causing pain with sexual
touching or intercourse, or with urination after sexual activity, or itching,
burning and even surface bleeding after sex. This can occur even in women
taking systemic estrogen therapy. As estrogen levels decline both the surface
skin and underlying connective tissues thin, shrink, and lose elasticity. Most
pain is actually located at the vaginal opening itself, rather than deep inside
the vagina as previously thought. The good news is that since these tissues are
exquisitely hormonally sensitive, even small doses of estrogen, with or without
testosterone or DHEA, applied to the vaginal opening (the vestibule), can
reverse these changes within 2-4 weeks, and then even lower doses can be used
to maintain the improvement. Some women with severe loss of elasticity will
also be helped by a course of pelvic floor manual physical therapy, to help
normalize the connective tissue, and relieve the reflexive muscle spasms that
some women develop due to their pain.
Q. I like your questionnaire (107-111)
because women often don’t know how to pin down just where and what the pain is
that they’re experiencing. I recommend that women scan or photocopy that
questionnaire to show their medical professionals. Would it be a good idea to
carry a copy of Healing Painful Sex to
the appointment, too, in case the doc hasn’t heard of your book?
A: One of our missions in writing the book is that women would have it as a
resource to get their gynecologists informed and up to speed on treating sexual
pain. Many patients have done just this, and their MDs have actually been
grateful for the introduction to the book.
Q. If a gynecologist says, “You just need
lubricant” or – worse! – “Well, at your age, you can expect that,” what should
an older woman say to get diagnosis and treatment? I tell women to say, “If you
don’t know how to help me, please refer me to someone who does,” but that might
seem more confrontational than you would recommend! What would you advise her
A: I would advise her to say exactly that. We have to advocate for
ourselves and we deserve up-to-date treatment for sexual pain. A healthy
sexual life is a basic human right, even defined as so by the World Health
Q. How can a post-menopausal woman weigh
the benefits of HRT vs. the health risks if she’s experiencing vaginal thinning
A: There is absolutely no evidence that the small amount of estradiol or
estriol available for use at the vaginal opening is absorbed to any degree that
would induce breast cancer. The doses are tiny compared to HRT doses that are
meant to be systemic, that is, to go to all parts of the body. To help hot
flashes the doses need to reach the brain in quantities much much higher than
the topical estrogen will ever give. And with the evidence now showing that
estrogen alone does not increase the risk of breast cancer anyway, women can be
assured that topical therapy, especially if mostly applied to the vaginal
opening, is safe. It is also now known that the thicker and more estrogenized
the vulvar and vaginal tissues are, the less absorption into the body. So
a stable constant regimen is better than going on and off the topicals, with
the tissues thinning again in between.
Q. How do we educate our medical
professionals to stop being dismissive and take our sexuality seriously,
whether we’re 60, 70, or 80?
A: This is a work in progress, but educational outreach through professional
societies like NAMS, the International Pelvic Pain Society (IPPS), and the
International Society for the Study Of Vulvovaginal Disorders (ISSVD), as well
as patient advocacy organizations, especially the National Vulvodynia
Association (NVA) is helping. The websites of these societies all list health
professionals by area to help patients find a knowledgeable MD. We also need to
devote more time to formal education on sexuality and pain in medical schools
and residency programs.