Dr. Hilda and Dr. Pat continue the conversation about vaginal health and sex after menopause.

Dr. Pat: Pelvic floor physical therapy is astonishing. It’s a great addition to my practice. And even though, Hilda, you and I both spend a lot of time with our patients and we enjoy the sex therapy aspect of our practice, we don’t have time to do one hour of physical therapy, teaching a patient all of the things that she needs to do while stretching and getting her to manipulate the genital tissue. Sometimes patients have tight hip flexors. I mean, everything is connected, after all. [Gesturing.] So women who are tight here may be tight here, and women who were ballerinas or gymnasts may have really overdeveloped pelvic floor muscles—

Dr. Hilda: Hypertonic.

Dr. Pat: Almost a rigid pelvic floor. The muscle between the vagina and the anus can be simply overdeveloped. And of course, if this is not addressed, every time the woman has painful intercourse, she begins to think about it being more painful, and then she develops a fear response so that she unconsciously clinches the vaginal opening, making all of this worse.

So I always ask when I examine someone, because there are certain things that gynecologists do as part of the routine pelvic exam. We check with a Q-Tip to see if there is a certain kind of response to gentle stimulation of the perineal muscle—you know, if I rub a Q-Tip on that perineal muscle and it goes into spasm, I know this patient might be having trouble with painful intercourse if she’s in a sexual relationship. And I can also tell, when the vagina will barely admit one finger, that nobody is having intercourse in this vagina.

Dr. Hilda: You were talking about the different types of estrogen that you can use in the vagina for women who are menopausal and want to have pain-free sex. I think it’s important to note that the Vagifem that you’re talking about does not give you systemic levels, so it doesn’t increase your risk of breast cancer.

Dr. Pat: And the dose has been decreased from the original 25 mcg dose—

Dr. Hilda: Yes, it’s only 10 mcg now.

Dr. Pat: —because there was concern that it could be absorbed. And there is a black-box warning mandated by the FDA with this product. So because there’s a black-box warning I say to patients, “I have to tell you that there is a possibility that some small amount of this can be absorbed.” Hilda, you and I believe strongly that it’s such a small amount, and it’s in a pill form—so it is less absorbed than other forms of estrogen.


The cream is more absorbed systemically, and seems to do a quicker job of revitalizing the tissue. You can insert it with an applicator into the vagina, and you can use, as I tell patients, a lima bean amount around the clitoris and a lima bean amount around the vaginal opening. Of course, you have to make sure that your patients have been in the kitchen or in the garden at some time in their lives. I once had a woman who came back to see me six weeks later and, boy, was she estrogenized. I said, “My goodness, you’re having quite a response to this small amount of local estrogen. Now, tell me again how large that lima bean was?” And she had been using green bean size, not lima bean. [Laughter] So I always make sure that the patient has at least heard of lima beans.

Dr. Hilda: And then, too, sometimes women are trying to make the vagina become moist faster. They want it right away.

Dr. Pat: So they get yeast infections by over-estrogenizing too quickly.

Dr. Hilda: Yes. They think that if they use more, it’s going to happen more quickly. But they don’t realize that they’re putting themselves at risk for absorption, and having high systemic levels of estrogen.

Dr. Pat: But I am very careful about having the follow-up within six weeks, so that everybody understands what the response is. And I describe what a yeast infection would feel like. I tell every person that they could have an allergic reaction to the estrogen cream. The compounding pharmacies make wonderful genital estrogen preparations for women who are allergic to some of the chemicals, such as propylene glycol or other preservatives, in either Estrace or Premarin cream. They can make capsules that dissolve with estradiol and olive oil, or they can make a liquid preparation.

Dr. Hilda: Now, Dr. Pat hates this type of vaginal estrogen—the Estring. She hates it.  But I—

Dr. Pat: Because the concept of something staying in your vagina for three months is just not appealing

Dr. Hilda: I’ve had a number of patients who absolutely love the Estring, because you put it in and you don’t think about it for three months, whereas—

Dr. Pat: Have you had a patient say that she had sex and the thing came out on her—on her partner’s penis?

Dr. Hilda: Oh. No.

Dr. Pat: Oh, yes. I have. [Laughter] And it was a new relationship. So I always warn patients who end up insisting on this form of estrogen. I say, “You might want to take it out before you have sex.” [Laughter]

Dr. Hilda: Really!

Dr. Pat: Well, I mean, how would you feel?

Dr. Hilda: Well, I’ve never heard of that happening.

Dr. Pat: How would you feel?

Dr. Hilda: Well, it would be embarrassing, yes.

Dr. Pat: It would be really embarrassing.

Dr. Hilda: I think that’s unusual.

Dr. Pat: I have heard about this twice. Not happy patients.

Dr. Hilda: But for the woman who doesn’t want to have to think about applying cream every Tuesday and Friday night or Monday and Thursday or whatever…

Dr. Pat: You know, I give this job to the husband. I send a little note home.

Dr. Hilda: For him to put the—

Dr. Pat: For him to make sure that she puts the estrogen onto the genital tissue. Because he is going to be motivated [laughter] to make sure she doesn’t forget. And everybody’s happy. She doesn’t have to think about one more thing to do, and he gets to participate.

In the next Sex Talk: Erectile dysfunction and female satisfaction.

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  • Catherine December 6, 2018 at 12:58 am

    I enjoyed the comments