Healing Painful Sex: Interview with Deborah Coady, MD

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.
I was happy to 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.
The authors are a 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.
I asked Dr. Coady if she would 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 to say?

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 Organization!

Q. How can a post-menopausal woman weigh the benefits of HRT vs. the health risks if she’s experiencing vaginal thinning and tearing?

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.

As always, I welcome your comments. If you’re experiencing pain with sex, I hope you’ll read both Naked at Our Age and Healing Painful Sex. Then please carry both books with you to show your doctor!

Erectile Dysfunction: Michael Castleman Talks to Women

Update note: I first posted this interview in June 2007. I have so many new readers now that I wanted to bring it to the forefront, because it’s such an important issue for both men and women. Often men feel they can’t talk about ED with their partners. Women tell me their men seem to emotionally disappear and avoid sexual activity and discussion. Michael Castleman helps all of us understand what’s going on. — Joan

In a previous post, I interviewed Michael Castleman, a sex educator, counselor and journalist specializing in men’s sexuality to answer some questions for men about erectile dysfunction. In this part of the interview, Castleman talks directly to women:

Q: What don’t women understand about erectile dysfunction (ED)?

MC: Like men, few women understand the difference between true ED and erection dissatisfaction. [See Erectile Dysfunction: Michael Castleman Talks to Men for explanation of the difference.] Women also don’t really appreciate how men FEEL when EDis or ED develop. It’s sort of like how women feel when they lose a breast to cancer. You’re still alive, but you feel diminished. A part of your body you took for granted isn’t there anymore, or in the case of men, doesn’t work like it used to. And this isn’t just any part of the body. It’s a body part that in a profound way DEFINES you as a man or woman. For women, loss of a breast raises issues like: Am I still attractive? Am I still sexual? Can I still please a man sexually? Men with ED and EDis wrestle with similar issues.

Beyond this, men have lived their whole lives pretty much taking their penises for granted: See a sexy woman, get hard. See porn, get hard. Think a sexual thought, get hard. Then all of a sudden–and in many men this happens pretty suddenly–they’re in a situation where they expect to have to rearrange their underwear to accommodate some swelling down there, and then….nothing. Nothing happens.

Many don’t understand what’s happening to them or why. But even those who do, me for example, feel surprised, upset, disappointed, depressed. Change is stressful. But when the changes concern the penis, well, men get seriously freaked out.

Now women often (and rightly) believe that men are too focused on the penis. That’s often true. It takes most young men years (sometimes decades) to leave penis-centric sex behind and understand the erotic value and pleasure of whole-body sensuality, a lovestyle more based on whole-body massage than on just sticking it in somewhere. Men who never get there, men who continue to view sex as penis-centered, when their penis stops behaving as they expect, they often think it’s the end of sex, that they’re over the sexual hill, that it’s all over. In my experience as a sex counselor and writer, few women appreciate how diminished men feel as they get used to EDis… if they ever adjust.

Q: Why can’t men express these concerns?

MC: Many reasons. In general, men tend to be less emotionally articulate than women. Men are socialized to be the “strong silent type,” to keep a “stiff upper lip,” to “grin and bear it.” In other words, to deny what they’re feeling and just go on. As a result, men get less practice than women discussing their emotions, and when they do, they’re less skilled than women. Now some women believe that men don’t HAVE emotions because they don’t discuss them. Wrong. Men feel things just as deeply as women. They just are less likely to discuss them, and if they do, they’re less likely to be able to really articulate how they feel.

The two genders have different natural histories of sex problems. With the exception of vaginal dryness, which is easily mitigated with lubricants, most women have most of their sex problems/issues when they’re young. Young women wrestle with the mixed messages that they should be sexy but not trampy, that they should want love/sex, but not want sex “too” much, not be “too” easy. But how easy is too easy? Young women also have issues with orgasm. Many don’t have them and have to learn how to release orgasms.

Meanwhile, few young men have sex problems–other than coaxing women in to bed. The young penis works just fine, thank you very much. Maybe the guy comes too soon (this is the #1 sex problem of young men), but only rarely do young men have problems with erection. Then they hit 45 or 50 and suddenly, the erections they took for granted their entire lives start to fail them. They freak. It’s almost unthinkable. Many Americans found themselves speechless after Sept. 11. It was so horrible, unimaginable. Men don’t discuss their ED or EDis in part because it’s unimaginable–then it happens and they’re speechless.

To many men, having reliable erections is a significant part of what defines them as men. If they have problems in the erection department, some fear that the women in their lives will view them as less than real men. So why talk about it? Why invite her to rub his nose in the fact that he’s less of a man?

Q: When should a couple seek counseling?

There’s no hard-and-fast rule on this. But when a problem festers, when you find yourselves having the same conflict over and over again, when there seems to be no way out, no resolution, basically, when you feel stuck, that’s when to consider counseling.

Now every sex problem is also a relationship problem and visa versa. If the main issue is power/control/decision making or conflict resolution, then a couples counselor is probably the place to start. But if they main problem is sexual–a desire difference, orgasm issues for the woman, erection issues for the man–then I’d start with a sex therapist.

Personally, I’m a fan of sex therapy. This is not self-serving because I am not a sex therapist. But studies show that two-thirds of couples who consult sex therapists report significant benefit within 6 months. That’s pretty good. Men with ED or EDis need to reframe their thinking about sex. They need to get away from porn-inspired sex and explore whole-body sensuality. This is often unfamiliar to men. They often fight it. So going back to a therapist week after week can help keep them on the path to self-discovery.

To find a sex therapist, visit the American Association of Sex Educators, Counselors, and Therapists (AASECT). Click the map of the U.S. and Canada, and get a list of all the AASECT-certified sex therapists in your state or province.

Q: What if the man won’t go?

The woman should go by herself. This is not as good as the couple going. But going solo gives the woman a place to vent. It may equip her with new coping skills that can help deal with the couple’s issues. And she may be referred to some written material, e.g. my book and others like it, that she can litter around the house and hope he picks up and checks out.

Great Sex
Michael Castleman, M.A., is the author of twelve books, including Great Sex: The Man’s Guide to the Secrets of Whole-Body Sensuality and Sexual Solutions: For Men and the Women Who Love Them. From 1991-95, he answered the sex questions submitted to the Playboy Advisor. Visit his website about sex after midlife, http://www.greatsexafter40.com/.

Satisfying Senior Sex for Women, Too!

Older people, especially healthy ones, and especially men, are enjoying sex, finds a study published in the British Medical Journal, March 9, 2010. Ellen Barnard, MSSW — sex educator extraordinaire and co-owner of A Woman’s Touch sexuality resource center — explains why women have been left behind and what they can do about it.

Satisfying Senior Sex for Women, Too!
by Ellen Barnard, MSSW

Older women stop having and enjoying sex sooner in their lives than men do, a study in the British Medical Journal found. That’s because the medical community has no idea how to help women maintain their sexual health and pleasure after menopause without the use of potentially dangerous hormones. Women don’t have any “little blue pill” to make things work better when their bodies have given up.

But the truth is, there are simple answers:

1. Live a “Good Sex Lifestyle” which includes daily exercise, a healthy diet full of fruits, veggies, nuts, whole grains and healthy fats and free of white sugars and flours, low-to-moderate alcohol intake, and daily doses of chocolate, Omega-3 oils and lots of Vitamin D. Healthy women enjoy good sex much longer than those in poor health.

2. At menopause and later, care for your vagina. Moisturize her daily or more with a good moisturizing lubricant (no glycerin), and massage her inner walls two to four times per week for five to ten minutes, with either a well-made vibrator or a partner’s fingers or penis. For more details, see our Vaginal Renewal™ program.

3. Have at least one orgasm per week, with yourself or a partner, it doesn’t matter. Keep those nerves functioning properly and remind them what pleasure feels like. If it’s hard to have orgasms, use a vibrator. Men use tools all the time, why shouldn’t you?

4. Get enough sleep, keep your stress under control, and keep a positive outlook. Your body will thank you for it, and your mind will be able to think sexy thoughts without distraction.

5. Think sexy thoughts, often. Fantasize, reminisce, create erotic stories in your head (or on paper), talk about sex, plan for sex, and make it a priority. Nurture your sex life, and it will love you back for many years to come.

– Ellen Barnard, MSSW is a sex educator and co-owner of A Woman’s Touch Sexuality Resource Center, which offers education and products to support healthy sexuality for everyone, with a focus on older adults and those living with cancer. She can be found at http://www.sexualityresources.com/.

I think Ellen’s information is vital, and I hope you’ll pass this link to your friends, colleagues, lovers, wives, and mothers. If more mid-life and older-age women knew these self-help strategies for enhancing their sexuality, there would be more satisfied smiles on their faces! — Joan Price

Restless Vagina Syndrome?


“‘Restless Vagina Syndrome’: Big Pharma’s Newest Fake Disease” by Terry J. Allen discusses the attempt to medicalize women’s sexuality as if we were men with faulty functioning who need fixing. Allen, senior editor of In These Times, writes,

It’s not your fault, ladies (and certainly not your partner’s), that you don’t orgasm every time you have intercourse, or that you lack the libido of a 17-year-old boy. You have a disease: female sexual dysfunction (FSD), and the pharmaceutical industry wants to help.

You are among the “43 percent of American women [who] experience some degree of impaired sexual function,” according to a Journal of the American Medical Association article. The FDA’s evolving definition of FSD includes decreased desire or arousal, sexual pain and orgasm difficulties—but only if the woman feels “personal distress” about it.

So, convincing women to feel distress is a key component of the drug company strategy to market a multi-billion-dollar pill that will cure billions of women of what may not ail them.

Allen goes on to describe the big pharmaceutical companies’ attempts to define women’s sexuality as men’s sexuality gone awry — we should get turned on easily and have mind-blowing orgasms every time — and their failed attempts (so far) to give us instant arousal and explosive orgasms with drugs. She discusses several drugs and how they have not turned out to be helpful to women.

I agree that we’re not defective men, and we absolutely should not fall for attempts to medicalize what might be perfectly normal. I encourage you to read Allen’s article in full. (I itched to retitle it “Restless Clitoris Syndrome,” however!)

On the other side, I hear from enough unhappy women (and men) to assert that we often DO have medical reasons that our sex functioning isn’t working the way we want, especially as we age. I encourage both women and men who are experiencing changes in their desire and/or ability to get aroused and experience orgasm to see a trusted medical professional. It’s important to learn whether there’s a medical reason for the change and to explore treatment options, if so. The right hormonal treatment, or a change in other medications that are affecting our sexual response, can make an enormous difference in our enjoyment of our sexuality.

If the change is due to psychological and/or relationship issues, then a counselor or sex therapist can make the difference between a dissatisfying or non-existent sex life and a richly rewarding one.

Doing nothing about an unhappy sex life only insures that it will remain the same or worsen.