Earlier in this series, Dr. Hilda and Dr. Pat talked about why orgasms are good for physical and emotional health. Here, the conversation turns to vaginal health and making sure that the terrific orgasms keep coming. 

Dr. Pat: Another topic that I’m frequently asked about is whether it is normal for women to have less powerful orgasms as they age—and if so, what can be done about it. It hasn’t been my experience personally, but I am asked that question a lot.

Dr. Hilda: It hasn’t been my experience, either, but I get that question, too.

Dr. Pat: It is a not infrequent complaint of postmenopausal women.

Dr. Hilda: What do you hear?

Dr. Pat: “Menopause has taken away the quality and the significance of my orgasm. It doesn’t last as long. It’s not as intense. What can I do?”

Dr. Hilda: Me, too. I have a lot of women who complain that the quality of the orgasm has changed, that it takes longer to get there, and when it does come, it’s not as intense, and it doesn’t last as long, that there used to be an explosion, and now it’s a little blip on the radar.  It’s very sad.

Dr. Pat: But it’s not uncommon.

Dr. Hilda: And when they come to me, they’re always in tears and feeling like life will never be good again. Because if you’re accustomed to have really great orgasms and you lose them, that can be very depressing. Very stressing.

Dr. Pat: So what do you tell them?

Dr. Hilda: Well, we usually do the whole hormone route. If nothing else has changed except decreasing hormones, we talk about estrogen, testosterone, progesterone.

Dr. Pat: But you surely don’t start estrogen and testosterone at the same time.

Dr. Hilda: No. We have that conversation.

Dr. Pat: Hilda, what would you say a woman should ask her gynecologist? And what should she be expect to hear back from the gynecologist?

Dr. Hilda: I think first you want to rule out all the medical problems and medications that can cause a change. For instance, antidepressants are huge in changing one’s orgasm.

Dr. Pat: Or any of the bisphosphonates, like Actonel, Boniva, or Fosamax. They absolutely destroy the genital tissue. Unfortunately, we have to weigh everything. The question is, do you want to have osteoporosis and fractures? It’s very hard to re-estrogenize genital tissue unless you stop the Boniva or whatever bisphosphonate you’re taking for a period of time. The simple thing is to stop the bisphosphonates for three or four months, have the patient take lots of vitamin D and the right amount of calcium and then use local estrogen. And when local estrogen doesn’t work, then there is the discussion about the use of a testosterone cream.

Dr. Hilda: We should say that testosterone is not approved for use in women presently, and when it’s used it’s used off-label. But there have been studies that show that testosterone increases sensitivity of nerve endings, and therefore makes it easier for some women to achieve an orgasm. It doesn’t work in all women, but in some women it does do that.

Dr. Pat: The studies are very much all over the place about this. so it’s not a first-line recommendation.

Dr. Hilda: Right.

Dr. Pat: The numbers of women that I have prescribed a testosterone cream for are less than ten. I  suggest many other options first.  Improvement of the genital tissue is always first, treating the  genital tissue to make it pink, moist and elastic. That includes stopping the offending drugs. Often women are begun on these bisphosphonates without the proper amount of vitamin D and calcium on board, and they actually don’t work in stopping bone breakdown effectively if the body doesn’t have quite a bit of vitamin D and calcium. Bisphosphonates seem to suck all of the vitamin D out of the genital mucosa. We don’t have studies to support this, by the way, so this is anecdotal description. But I can certainly tell you that these drugs cause severe genital atrophy, change in the genital mucosa, and pain with intercourse in almost every woman who uses them unless she also uses something else.  Once the genital tissue is normal again, then I have the vibrator discussion.

Dr. Hilda: I’d also like to talk about women who may be facing some physical disabilities. In other words, what if your vagina is fine but your hips are not? Osteoarthritis, rheumatoid arthritis—

Dr. Pat: Or scoliosis. In other words, some significant postural deformity.

Dr. Hilda: Or just pain. You just can’t flex your hips. Pat, what do you advise patients who are in a relationship and want to remain sexually active, but are facing physical hurdles?

Dr. Pat: For one thing, if you have bad knees, you are not going to do missionary sex on top. Spooning sex—entry into the vagina from the spoon position–is very comfortable for most people. And a woman can put a pillow between her knees so she can have flexion of the top leg, and there’s more room. Usually that’s a very comfortable position, and she can have clitoral stimulation, and breast stimulation while her partner enters her from behind.

Dr. Hilda: I always say, “Where there’s a will, there’s a way. And we can make it work.”  Using pillows is great. You can always support the part of the body that is experiencing pain by using pillows in strategic locations. There is always a way of making this work, and sex is so many different things. We tend to focus so much on intercourse, but it can be so much more than that.

One of the things I do with my patients who have arthritis is to time the medication so that they’re taking the medication an hour before they expect to be sexually active.  I also recommend a warm bath—

Dr. Pat: Always.

Dr. Hilda: —to kind of relax some of the joints and make them more flexible.

Dr. Pat:  I also think it makes the clitoris more engorged.  A warm bath and thinking about sex.  That should do it.

Dr. Hilda: It does. That heat is wonderful.

Dr. Pat: Right. And if you have a Jacuzzi, well, you don’t want to stay in there too long.

Dr. Hilda: Sometimes it’s great to have sex in the Jacuzzi, too, if you have these joint problems.

Dr. Pat: Yes. It all depends on the position. It has to be a big Jacuzzi.

Dr. Hilda: (Smiling) It has to be a very big Jacuzzi for some of us, yes. But there’s always a way of making it work. You have to be a little adventurous and willing to try some new things and think outside the box. So it’s not just the missionary man-on-top position, but finding a position that works for the two of you is important.

Dr. Pat: Doctors across the board who care for their patients—the specialists in pain management, the specialists in rheumatoid arthritis or arthritis management—could do their patients a great service by asking a simple question: “Do you find sexual activity painful?”  And if the woman says, “Yes, and I’m also afraid of hurting myself, or I’m afraid that it will be to awkward for my partner,” doctors and health professionals could do such a great service. They could educate their patients, and invite the sexual partner in if the patient is agreeable, to talk about this way of not just focusing on the pain, but focusing on living.

Dr. Hilda: Right.

Dr. Pat: Gynecologists who want their patients to have a good sex life should encourage patients to talk to all their doctors about impediments to sexual satisfaction. And we can talk to the specialists as well. “What do you say, Dr. Jones, rheumatologist, to your patients when they say they have pain when they have sex in certain sexual positions?”  Or “I have a hip that needs to be replaced but I’d still like to have sexual activity. Do you have any suggestions?” I think that this is a wonderful way of providing language not just for women to use when they talk to a potential new partner about condom use and sexually transmitted disease, but to talk to their health care provider team, too.

Next: Long-Term Relationships and Keeping That Spark Alive.