Frustrated in Florida, age 61, had not had sex for nearly 12 years, until recently. She wrote in an email to me:
Apparently one’s vagina does change after not using it for a long period of time. I always thought sex was like riding a bicycle, but it is not. One can’t just get back on and ride! I experienced such pain during the attempted penetration that we had to stop. What a disappointing and embarrassing moment. My partner was very understanding, however I was just frustrated and disappointed.
I went to my GYN for an examination soon after and explained my circumstances. She gave me a thorough exam and said although I had many tiny lacerations and redness, my vagina seemed normal. She explained how one’s vaginal lining becomes thin after menopause and her advise was to abstain from sex for two weeks, using lubrication to aid in healing.
When we engaged in sex again, very gently, I was once again disappointed with the level of pain even though using lots of lubrication. We once again had to stop.
So now I am wondering if there is some way I can stretch my vagina for it seems like it has shrunk. (Perhaps it is just my imagination running wild!)
Have you had anyone else write you with a similar problem and if so is there a solution? For your information I have never been on hormones and my partner’s penis is of normal size.
No, it’s not your imagination, and yes, it’s true that the vagina will seem to shrink after a long period of abstinence, especially after menopause, and penetration will be painful or sometimes impossible. You’ll find a helpful chapter in my book, Naked at Our Age: Talking Out Loud About Senior Sex and several other posts about vaginal pain on this blog.
I’m disappointed that your gynecologist is not this helpful. Telling you you’re “normal” while you have lacerations and pain is not helpful, is it? Most doctors do not know how to diagnose or treat vaginal pain, and it ‘s wise ask for a referral to a sexual pain specialist.
Please read Vaginal Renewal Program by Myrtle Wilhite, M.D., at A Woman’s Touch, a wonderful sexuality resource center in Madison, WI. It tells you step by step how to massage and stretch your vagina. Here’s an abridged version:
* External Moisturizing and Massage: Increase the suppleness and blood circulation of the skin of your vulva and vagina with a five- to ten-minute massage with a moisturizing sexual lubricant like Liquid Silk®, a water-based lotion that will soak in and moisturize your skin, won’t get sticky, and will help you massage with very little friction.
Push in to the skin with circular strokes, and massage what’s underneath the skin, rather than brushing across the skin. Include the inner lips, the hood of the clitoris, the head of the clitoris and the perineum.
To complete your external massage, massage into the opening of the vaginal canal, using the same circular strokes. The massage itself does not need to be self-sexual in any way, but if that is comfortable for you, by all means explore these sensations.
* Internal Vaginal Massage: To massage inside your vaginal canal, we suggest using a lucite dildo which is very smooth and will not cause friction or tearing. Choose your size based upon how many fingers you can comfortably insert into the opening of your vagina.
After a session of external vulva massage, apply the same massage to the inner surfaces of your vagina with your dildo with lubricant applied on both skin and dildo. Rather than pushing the dildo in and out, use a circular massage movement. You are increasing skin flexibility so that your body can adjust to comfortable sexual penetration if you choose it.
You might also choose to use a slim vibrator for massaging the vaginal walls. Coat it in Liquid Silk and then insert it gently. Turn it on and let it run for about five minutes. You don’t need to move it around, just lie there and let it do its work.
* Orgasm: For women who stop having orgasms, the blood vessels literally can get out of shape, preventing future orgasms. If you are able to bring yourself to orgasm, do so at least once a week (for the rest of your life — seriously). This is preventive maintenance of your body.
* Kegel Relaxation: Kegels increase both the strength and flexibility of your pelvic floor muscles. Pay attention to the relaxation and deep breath part of the exercise. Learning to relax your pelvic floor will help you to avoid tensing up before penetration. (Read A Woman’s Touch’s Step-by-Step Kegels in this article about pelvic floor health.)
In my earlier book, Better Than I Ever Expected: Straight Talk about Sex After Sixty, I had interviewed a 75-year-old woman who had been celibate for 38 years and was in a new relationship. She was unable to have intercourse because her vagina had dried and narrowed to the point that penetration was impossible. She sought help from her gynecologist (a wonderful woman who bought dozens of copies of Better Than I Ever Expected to give to her patients!), who helped her.
June has been declared Adult Sex Ed Month (#AdultSexEdMonth) by Ms. Quote
(@GoodDirtyWoman on Twitter) who blogs at A Good Woman’s Dirty Mind. This idea caught on, and this month, hundreds of posts designated #AdultSexEdMonth from sex educators and bloggers appeared all over the Internet. View the list with links here.
In my world — advocating for senior sex and educating about older-age sexuality — every month is Adult Sex Ed Month. This month has been particularly fruitful.
This month, I participated in a Huffington Post Live event titled “How Old Is Too Old To Have Sex?” with fellow panelists Ashton Applewhite, Walker Thornton, Sidney Schwab, and Ken Solin, hosted by Abby Huntsman. Of course the answer to the question in the title is obvious to us (though not obvious to Abby, until we raised her consciousness), but you’ll find the discussion interesting even though you know the answer! Watch it here:
The annual conference of the American Association of Sexuality Educators, Counselors
and Therapists conference always makes my brain swell with new information and ideas from sex educators who are trailblazers in the field. Counselors, therapists, sex educators in community or medical settings, and other people who care about your sexual knowledge and enrichment gather to learn from the leaders. Then people like me come home and spread it around – to people like you.
As always, it was impossible to attend all the sessions of interest, and there’s no way I can share all of the 25 pages of single-spaced notes that I took on my laptop, no matter how many blog posts I write. But here are some highlights and tips that are especially relevant to our age group:
- Some sexual issues are psychological; some are medical or physiological. But even when it’s a medical issue, a sex therapist can be important to help you work with whatever is going on. Medical sexual issues affect your sense of self and your relationship. “Any pharmacotherapy for sexual dysfunction should occur within the context of sex and relationship therapy.” (Ricky Siegel)
- One more good reason to quit smoking: Nicotine has been shown to decrease blood flow to the penis and increase venous outflow from the penis — in other words, less ability to get and maintain an erection. (Ricky and Larry Siegel)
- Women with vulvar or vaginal pain have a difficult time getting the pain diagnosed and treated effectively. Possible causes of pelvic pain are varied, and with the wrong diagnosis (or no diagnosis!), the wrong treatment follows. Look for a three-pronged approach: a sexual medicine physician, a pelvic floor physical therapist, and a certified sex therapist, such as used by the Summa Center for Sexual Health in Akron, Ohio. (Kimberly Resnick Anderson)
- Pelvic floor physical therapists are trained to do internal evaluation of the pelvic floor muscles — evaluating muscle function, strength, tone, and any points of tenderness. Regular physical therapists are not trained to do this. (Amy Senn)
- Men with low libido: Anxiety, mood, relationship, and religious factors affects libido. “First know what’s going on in the relationship before throwing medication at it.” (Larry Siegel)
- “Nerve sparing” prostate surgery is “a bit of a misnomer.” Erectile nerves on the outside of the prostate are very difficult to see and avoid during surgery. “The prostate is deep in the pelvis, and they go pushing around with stainless steel instruments. If cauterizing instruments are anywhere near nerves, it damages them for life. Nerves recover from the pushing and pulling – it takes a long, long time. Nerves go into shock and stop sending message to blood vessels to relax and let blood in.” (Anne Katz)
- “Sexual arousal requires healthy blood flow for everything else to work. Otherwise, nothing happens. Take a 15 minute walk with your partner before sex. It will prime the pump.” (Ellen Barnard)
- After treatment for female genital cancer, using a vibrating wand internally will reduce scar tissue. “Vibration directly to the scar tissue starts breaking up that scar tissue, allowing it to expand, become more comfortable, and allow penetrative sex if we want it.” (Ellen Barnard)
- After cancer treatment, start getting to know “what is”: “What feels good? What doesn’t feel good? What’s numb? What’s painful? How does arousal happen? What does it take? How does orgasm happen and feel? When during the day do I have energy?” (Ellen Barnard) You need to learn this for yourself before you can teach your partner. (JP: This applies to aging in general, also.) A Woman’s Touch has excellent educational brochures for both men and women online at no cost, for example, Healthy Sexuality After Cancer. Visit www.sexualityresources.com, see the Educational Brochures link in the upper left hand corner of the menu bar for a complete selection.
The huge news this month for me as a senior sex educator was an invitation from Cleis Press to write a book for them: The Ultimate Guide to Sex after Fifty! I’m thrilled to have a new book to write on my favorite topic, and I’m proud to be part of the fabulous Ultimate Guide collection of sexuality guidebooks. You can be sure you’ll hear more about my new endeavor as it unfolds.
Meanwhile, if there’s a topic you want to be sure that I cover in this new book, please either post it as a comment here or email me. I love to hear from you. I’m too busy to promise to answer all your questions in detail, but I try to acknowledge your email and point you in the right direction. I admit sheepishly that I have about 400 unanswered emails waiting. If one of these is yours, I thank you for your patience! (I do give private, educational consultations answering your questions by phone or Skype for a modest fee — email me for more info about this.)
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.
One of the most helpful chapters in Naked at Our Age (coming June 2011) addresses vulvar/vaginal pain, a complex issue. You’ll read real-people stories from women whose vaginal or vulvar pain prevented them from enjoying penetration, or who learned how to renew their vaginal health, plus information and direction for getting your own pain diagnosed and treated. Although you’ll have to wait for the book, until then, these posts about vaginal/vulvar pain will be helpful, and here is a list of websites that offer more information and/or referrals to knowledgeable professionals:
• American Association of Sexuality Educators, Counselors, and Therapists: http://www.aasect.org/.
• American Physical Therapist Association, Section on Women’s Health: http://www.womenshealthapta.org/.
• American Urogynecologic Society: http://www.augs.org/.
• International Society for the Study of Vulvar Disease: http://www.issvd.org/.
• Mypelvichealth.org: http://www.mypelvichealth.org/
• National Vulvodynia Association: http://www.nva.org/
• OObgyn.net: http://www.obgyn.net/
• Pelvic and Sexual Health Institute: http://www.pelvicandsexualhealthinstitute.org/
• Secret Suffering: Helping Women Cope with Sexual and Pelvic Pain (patient site): http://www.secretsuffering.com/.
• Vulval Pain Society: http://www.vulvalpainsociety.org/.
• Vulvar Pain Foundation: http://www.thevpfoundation.org/
• Vulvodynia.com: http://www.vulvodynia.com/