In this installment of the ongoing conversation, Dr. Pat and Dr. Hilda talk about what it takes to keep older vaginas healthy and ready for action.

Dr. Pat: Hilda, do you have many patients who complain that, you know—

Dr. Hilda: They look terrible?

Dr. Pat: —that their labia have become elongated and droopy.

Dr. Hilda: All the time.

Dr. Pat: I find it to be so odd. I mean, I have had in my entire practice perhaps three patients who truly have had discomfort with intercourse because the labia were unusually long, and would get caught when the penis was entering in the vagina, and make it difficult for them to be orgasmic. But I think the risk of having labioplasty—

Dr. Hilda: It’s also called vaginal rejuvenation.

Dr. Pat: Right, or labioplasty—meaning that they’re going to use laser, generally, to refine the shape of the labia, make them more pre-pubescent looking.

Dr. Hilda: They look like babies.

Dr. Pat: They look like little girls’ labia. And then, if they’ve had children, and don’t have other symptoms of a dropped bladder or symptomatic vagina opening issues—if they don’t have those symptoms, but don’t like the fact that their vaginal opening is not small, they think they should have that fixed as well. And Hilda, you and I both know that there’s nothing more unpleasant for a postmenopausal woman than to have a stenotic vaginal opening—you know, so tight that it causes painful intercourse.

Gynecologists often see women who’ve never had a vaginal birth who have gone through menopause and may no longer be having intercourse on a frequent basis, because they have not been in a consistent sexual relationship. These women often have not have been using any kind of genital estrogen. Then they meet someone and are having a nice relationship and decide to take it to the next level without checking with their gynecologist. Often they’re horrified because it’s so painful they frequently can’t have intercourse. It’s very distressing.

It’s very important that a woman who fits this profile understand that before she begins a sexual relationship, if she has been celibate for some period of time and is menopausal, and especially if she has never had children—or never had a vaginal birth—that she check with her gynecologist before she plans to begin a sexual relationship. It can take about six weeks to get the tissue thickened and elastic again.

We usually use an Estradiol cream on the outside, and a Vagifem pill that goes into the vagina, though not on the same day. Every other day for a couple of weeks, and then decrease it to two or three times a week. I suggest that women whose blood levels of calcium are normal also take high doses of vitamin D short-term—one month or so—which improves the thickness of the layers of the vaginal tissue. The major reason that women develop painful intercourse at this time of life is not only that the vaginal opening is small and tight and inelastic, it’s also that the genital tissue is so very thin. So it gets easily abraded or worn off with friction, even with lubrication.

I have a number of patients who have called me, despondent. “There’s something really wrong with me. I tried to have sex and it was so painful I had to stop, and I was so embarrassed. What am I going to do? I have to see you right away.” However, I try to bring the subject up as a part of the annual visit. I always offer the patient a chance to discuss sex. I say things like “Are you seeing anyone?” And I often hear, “No, there is not one, not one dull man left in New York City who isn’t gay.” [Laughter]

Dr. Hilda: And patients may need dilators. We have medical dilators, and I often start with those when there is a stenotic, inelastic vaginal opening. If a patient comes in and you  notice that her vagina is stenotic, or small and tight, not only do you give the estrogen, but after they’ve been estrogenized you prescribe the dilators. I usually just have them go on to a website. There are several websites where you can buy vaginal dilators. My favorite is vaginismus.com, but it is important to speak with your gyno for recommendations and instructions.

[Dr. Pat leaves momentarily and returns with a plastic bag of different-sized dilators.]

Dr. Hilda: They’re over-the-counter, not prescription. [Inspects the bag Dr. Pat has brought in.] These are from a surgical supply store and do require a doctor’s prescription. The over-the-counter ones work as well for most patients, but some insurance companies cover only the ones from a surgical supply store.

Dr. Pat: [Takes bag and holds it up, gesturing to the largest dilator] This is known as the Big Boy, by the way. [Laughter] I have never seen a penis that large.

Often, I have the most amusing conversations with patients when they return for evaluation after using the dilators. Most of them have husbands who want it known that they are a Number 4! They say, “Make sure you tell Dr. Allen that I’m the Big Boy.” [Laughter] They all want me to know that. In my gynecologic practice, I apparently have the most extensive collection of ‘Big Boy’ husbands in America!

The funniest thing about the dilators is that when I send these home, I tell patients that for the postmenopausal woman, the small penis is fine. Many post-menopausal women who have experienced painful intercourse are much more interested in men with smaller penises. At last, the small guy is king!

[Crosstalk and laughter]

No, no, no, no, no, no, no.  This is very important.  [Picks up the bag and points again to the largest.] This is the Number 4 dilator out of a series of four. The woman will work with Number One, and then she’ll work with Number Two, and then generally come back for me to help her insert Number Three. She inserts them while lying down in bed.

And you know, I have to remind her, because some women may not know that the vaginal canal is in a posterior position—directed toward the rectum when a woman is lying down. If a woman is having pain with intercourse, another thing she has to learn is make sure that the rectum is empty. Because a constipated rectum full of stool will push the vagina anteriorly and cause bladder infections and pain. Who would know?

If a patient has had comfortable intercourse in the past and has restored the health of her genital tissue, but she continues to have pain when the penis enters the vagina, I often recommend an evaluation by a pelvic floor physical therapist. I work with two physical therapy groups here in New York City. It’s generally three sessions a week for 12 weeks. They’re educational. The female therapists get right in there with gloved fingers, teaching patients about breathing exercises, relaxing, biofeedback, the anatomy, the physiology, how to change position. And there are exercises that patients are given to do at home.

In the next Sex Talk, more about pelvic floor physical therapy, and how much, when, and where to apply genital estrogen.