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Dear Dr. Myrtle,
I am a cancer survivor in menopause. I don't want to use estrogen but I am dry and sex is getting more painful. What can I do?
We have put together a program for women who are currently sexually active with vaginal penetration, and are experiencing dryness and discomfort or pain during intercourse that is either diffused throughout the vagina or burning or tearing at the vaginal opening.
How to maintain a healthy vulva and vagina during and after menopause
- The Process of Menopause
- Comfortable Vaginal Penetration
- What is the Vaginal Renewal Program?
- Part 1: Moisturizing the Skin of Your Vulva and Vagina
- Part 2: Massaging Your Vulva
- Part 3: Internal Massage Using Vibration
- What to do if You Have Pain and/or Bleeding
- How Does it All Go Together?
- Other Sexual Health Tips
The Process of Menopause
As a woman goes through menopause, the level of estrogen in her body decreases. In the case of natural menopause, this happens gradually. In the case of medical menopause (caused by surgery or chemotherapy), it happens abruptly. Whichever way menopause occurs, the decrease in estrogen can cause a number of symptoms, including thinning of the skin of the vulva and vagina, and/or a decrease in vaginal lubrication. This may result in discomfort or pain with touch or penetration, whether in a sexual context or during gynecological exams.
Having symptoms that make sexual contact difficult, uncomfortable, or painful can make you feel like your sex life is over. But whether you’re single or partnered, there’s no reason this has to be the case. The Vaginal Renewal program was designed by A Woman’s Touch to provide information and tools that can help to maintain sexual health and well-being during and after menopause regardless of the use of hormones.
Women who can benefit from the Vaginal Renewal program range from those just beginning to feel the effects of hormonal changes, to women who have had dryness and thinning of the skin for so long that when they attempt penetration they experience skin tearing and pain. Women who are using estrogen cream, gel, or the Estring will find that the Vaginal Renewal program is completely compatible with estrogen therapy, and the combination can be more effective and faster-acting than estrogen alone. Many women have enough improvement from the combination of estrogen therapy and the Vaginal Renewal program that they are able to, over time, decrease or discontinue the use of estrogen.
Comfortable Vaginal Penetration
Comfortable penetration depends on the flexibility of two different structures: skin and pelvic floor muscles. The Vaginal Renewal program will help you recondition the health and flexibility of the skin of the vulva and vagina. However, some women recondition their vaginal skin only to experience uncomfortable penetration because their pelvic floor muscles are inflexible. If you have this difficulty, see the section titled Pelvic Floor Strength and Flexibility.
What is the Vaginal RenewalTM Program?
The Vaginal Renewal program has three parts:
Moisturizing, Manual Massage & Vibrating Massage
Ideally, we recommend that you do all three parts of the program daily for the first month, and then do them twice a week, indefinitely. Depending on your circumstances, you might want to continue daily for longer, or you may only periodically need the therapy, with rest periods in between.
For women who have used this program, the most dramatic results occurred when all three parts were done at least weekly, but sometimes that’s just not possible. Fortunately, any portion of the Vaginal Renewal program that you can find time for, will help. You don’t have to do every part, nor do it every single day, in order to obtain results. If some aspects make you feel uncomfortable, skip those and do the others. They all work to increase moisture and tissue health, so do what seems right for you.
Part 1: Moisturizing the skin of your vulva and vagina
Choosing a Lubricant:
Genital moistness and vaginal lubrication are directly related to blood circulation, since lubrication comes from blood which is filtered through the spaces between skin cells, not a gland. Anything that interferes with small blood vessel circulation (antihistamines, lack of exercise, high blood pressure) reduces genital lubrication, and can leave an uncomfortable feeling during sexual intimacy and for some, regular daily activities. Estrogen increases small vessel blood circulation, so many women experience some level of vulvar/vaginal dryness as blood levels of estrogen naturally decrease during the transition through menopause.
Lubricants applied directly to the skin are a great solution for vaginal dryness, but choosing the right one is important. Two main features of lubricants--whether they add moisture to the skin and/or whether they seal in moisture--should be considered when making your choice. Unfortunately, most commonly used lubricants are neither moisturizing nor do they seal in moisture! See chart 1, page 5. After choosing a few, experiment with different lubricant samples to find the one(s) which feel the best to you.
For the Vaginal Renewal program, we recommend lubricants which both add moisture and seal the moisture in place. Our most successful lubricants for Vaginal Renewal are Oasis Silk, Erosense Sync, and Sliquid Organics Silk which both add moisture to the skin and seal it in. The pH of Oasis Silk is 5.2--ideal for most women. If you happen to be one of the few women with an allergy to propylene glycol, try an alternative lubricant like Sliquid Organics Silk or Erosense Sync.If you are allergic to onions, garlic or aloe vera, try the Sutil Luxe. The Sutil will add moisture but not seal it in.
How to Moisturize:
You can use your moisturizing lubricant just like you would a facial moisturizer, except it’s used on your vulva. Smooth it on any time during the day that you feel dry. You can also insert it into your vagina using a needle-less syringe or dropper, at bedtime, to moisturize your vaginal tissues all night long if you experience discomfort on a daily basis. Insert 1-3 ml when you go to bed, and sleep on a towel. Most women soak that entire amount up; if you try 3 ml and find some comes out as discharge, try less the next night.
You can also use your moisturizing lubricant for sexual penetration. If you are having sexual intercourse with a partner, you will want to have your partner use a silicone lubricant such as FeMani Smooth Touch or Uberlube. This combination will keep things slick and help prevent small tears or excess friction with both external touching and penetration, whether you’re self-pleasuring, or with a partner. Coat all body parts and any toys that will come in contact with your vulva and vagina; you can even insert some into your vagina before penetration. If you use toys, your water-based lubricant can be safely used with any material.
Is moisturizing something I should be doing?
If you are experiencing vaginal dryness , the moisturizing portion of the Vaginal Renewal program is very important. Fortunately, it is neither time-consuming nor particularly inconvenient for most women. Many women find that doing the external massage prior to sexual contact also boosts their pleasure by increasing arousal.
If you use male condoms, and find that there is too much friction or that they seem to break easily, massage and lubricate yourself prior to penetration. Often condoms do not have enough lubrication in the package to last for a whole session, so add your own both on the inside of the tip of the condom, and on the outside. For this we recommend using a silicone lubricant like the FeMani Smooth Touch.
If you lubricate, but not as quickly as you used to, you might benefit from using a lubricant when you have sexual contact. It will keep things slick right from the start and prevent uncomfortable friction that can lead to tiny tears in fragile tissues. If you feel you have plenty of moisture already, that’s fine too. Do what feels right for you.
If you are experiencing pain or bleeding with penetration, this moisturizing regimen is extremely important. We encourage you to do it every day, in conjunction with the vulva massage portion of the program, outlined next. We also strongly recommend that you abstain from vaginal penetration for a few weeks to give your fragile internal tissues time to heal while you continue moisturizing.
Part 2: Massaging Your Vulva
How to Massage
This is a different kind of massage than you might be thinking of. Rather than applying friction to the skin (rubbing, stroking), the aim here is to press and release. You will be pressing the old fluids out of your skin tissues which allows fresh blood and lymph to flow into the area; this is how your body rebuilds from the inside out. The press-and-release massage encourages your skin layers to become more flexible, with better blood flow and thicker, more resilient tissue underneath. The entire massage should take about 5 minutes.
You might want to practice the press-and-release motion on the back of your hand. Just press your fingertips onto the back of your hand; it should feel comfortable but firm. Now lift your fingers off, and watch the paler skin on the back of your hand turn back to its normal color. You have just watched the fluid exchange that leads to healing. Remember, do not rub. You should feel pressure, not friction.
Now, try this on your vulva. The goal is to press and release every bit of skin and tissue on your vulva, beginning with your outer lips. First, apply a dab of lubricant and smooth it lightly around so everything is slick. Then, begin to press and release, using two or three fingertips, working your way around the outer lips of your vulva. It might help to think of a clock face, and work your way from 12:00 around and back to 12:00 again.
When you are finished massaging your outer lips, massage your inner lips. If you need more lubricant, apply some. Press the inner lips between your thumb and fingertips, with a gentle, squeezing motion. This should not hurt; your goal is just to move the blood out, and allow it to return. Work your way all around the inner lips on both sides, and up to the clitoris. Press and release on the clitoris and clitoral hood, too.
Next, massage the area around your vaginal opening. Press and release all around the opening, from 12:00 to 12:00 again.
The last area you should focus on is your perineum--the skin between your vaginal opening and anus. The flexibility of the perineum is crucial for comfortable vaginal penetration, so if you’re having pain with penetration, be sure to include this part.
Apply ample lubricant to your thumb and index finger, and gently insert your thumb into your vaginal opening. Press down into the skin of your lower vaginal wall (toward your anus) with your thumb while gently squeezing the tissue of the perineum with your index finger. Concentrate on relaxing the muscles underneath the skin by gently sweeping your lubricated thumb from side to side. You are not trying to stretch the skin, but rather help it become more flexible.
Who should do Vulva Massage?
If you are not experiencing thinning of the skin, or “vaginal atrophy” as your physician might call it, vulva massage can be used as an effective preventive measure. Prevention is generally preferable to developing a problem and then treating it, so if you can work this into your schedule, we recommend it. If you don’t feel you have time for it now, remember it for the future when you might need it. In the meantime, you might choose to increase blood flow to your vulva by having at least one orgasm a week, doing Kegel exercises for your pelvic floor (take a look at our article on Pelvic Floor Health for Women) and increasing how much area of your vulva you touch when you self-pleasure. Any increase in blood flow to the area is helpful for maintaining skin integrity and lubrication.
If you are already experiencing vaginal atrophy, the external massage is likely to be helpful and will prevent your symptoms from worsening. If you occasionally have some discomfort (but not pain or bleeding) with penetration, be certain to include the perineal portion of the massage, and use lubricant, including silicone lubricant when you attempt penetration.
If you have pain with sexual touching on your vulva, the entire external massage with lots of moisturizing lubricant may be very helpful to you. However, if it turns out that it is painful to massage, begin with just the moisturizing portion of the Vaginal Renewal program and try the massage again after a week or two of frequent moisturizing. If you are still too uncomfortable to massage, consult your health care provider to determine the cause of the problem.
If you have pain or bleeding with penetration, massaging the areas around your vaginal opening, perineum, and inner and outer lips is crucial. Pain or bleeding with penetration can lead to the development of non-stretchy scar tissue on your perineum. By moisturizing and massaging the area, you will be restoring flexibility to the perineum as well as increasing the flexibility of the surrounding tissue. The more flexible and stretchy all the tissues in the area are, the more likely that you will be able to have comfortable penetration. Just be sure to go slowly, take your time, and breathe. Remember, you’re in control of this, and it should not hurt! Your goals are to increase flexibility and blood flow, and to be able to relax while experiencing touch in that area. (See the section on Pelvic Floor Strength and Flexibility if you are having problems relaxing your muscles during penetration).
Part 3: Internal Massage Using Vibration
By using a vibrating wand internally, you can accomplish the same sort of press-and-release massage inside your vagina that you are able to do with your fingertips on your vulva. Just like on your vulva, this kind of internal massage creates an exchange of old blood and lymph for new, allowing your body to create stronger, healthier layers of skin.
Also, medical studies show that vibration is uniquely able to increase tissue strength--in particular, the kind of strength that resists tearing. This is because the small movements made by the vibrations gently tap the skin while increasing the amount of blood that can flow to the vaginal wall. Vibration is also effective at breaking up scar tissue. If you are squeamish about using something referred to as a “vibrator,” remember that this is an important therapeutic measure. You can improve your skin integrity without using a vibrating wand, but the progress is much slower, and often less progress is made. If it is also pleasurable, that’s fine, but the primary intention is to help restore health and elasticity to your tissues so you can be comfortable with pelvic exams, or enjoy sexual penetration if you wish.
We recommend doing the internal massage with the vibrating wand every other day for 5-10 minutes at a time. More often is NOT better; take it slow and if you want to do it every day you can do that after 2-4 weeks of every other day.
Maintenance is every 2-3 days once you are comfortable and not having dryness or painful penetration.
Choosing Your Vibrating Wand:
You will be using a vibrating wand to accomplish the internal massage. The wands are made of smooth plastic to minimize friction, and come in several sizes. It is important to choose the one that is right for you. To do this, first determine how many lubricated fingers you can comfortably insert inside your vagina when you are not aroused. This might be one, two, or more than two fingers. Then choose the vibrating wand that corresponds in width: Size 1 is approximately one finger-width, Size 2 is between one and two finger-widths, and Size 3 is between two and three finger-widths.
How to do the Internal Vaginal Massage:
First, coat the wand with your moisturizing lubricant, and then gently insert it into your vagina to a comfortable depth. If possible, it is best to insert it at least several inches. Then, turn the dial to a medium vibration setting, and relax for five minutes while the wand does the press-and-release massage for you. You can read, or just breathe during this time. Just let the vibrations do the work. There is no need to move the wand in and out or from side to side.
Over time, as you experience increased skin flexibility, you might choose to move up to the next larger size wand. If you can comfortably slip a lubricated finger into your vagina next to the wand, you can feel confident that the next size wand will be comfortable. Don’t rush it; the internal massage should never be painful. By the time you feel comfortable inserting Size 3, pelvic exams should be comfortable as well. If you have a gynecological exam before then, ask your care provider to use a smaller sized speculum for your comfort, if necessary.
During the process of reconditioning your skin, you may see a thin smear of dilute blood, which is normal. However, if you notice red bleeding from your vagina, stop this portion of the program and consult your health care provider to evaluate the condition of your skin and rule out other problems. If you feel as if the wand “hits a wall” and you cannot insert it, or if insertion causes muscle cramps, see the section What to Do if You Have Pain and/or Bleeding with Penetration.
Who should do Internal Vaginal Massage?
If penetration is becoming uncomfortable for you, and you think you might want penetration to be a part of your life now or in the future, or if you are uncomfortable during pelvic exams, the internal massage portion of the Vaginal Renewal program may help. If your tissues become less flexible, thinner, drier, or more fragile, your vagina might not be able to accommodate any penetration without pain. Vibrating massage with moisturizing lubrication can prevent or reverse this process.
If the vibrating wand makes you nervous and you just don’t want to use it, but you feel comfortable touching your vulva and vagina with your hands, you can do the internal massage with your fingers, using some moisturizing lubricant. It won’t be quite as effective, but it will certainly increase blood flow to your internal tissues, which is a large part of the goal. You might have to experiment a little to find a position that is comfortable for you to reach, or if you have a willing partner, he or she could help. Just insert one or two lubricated fingers vaginally, and press gently in every direction. Try to massage for about five minutes.
If you are not experiencing discomfort with penetration, just store this information away for future use. However, if you don’t frequently experience any kind of penetration that could alert you to symptoms developing, we recommend that you do this internal massage periodically as a preventative measure and so you can recognize early signs of change. Increase the frequency of the massage when and if necessary.
What to Do if You Have Pain and/or Bleeding with Penetration
Comfortable penetration depends on the flexibility of two different structures: skin and pelvic floor muscles.
Skin. Pain and/or bleeding with penetration may result from dryness, friction, and small tears in the skin of the vagina.
It’s important to distinguish between healthy “micro-tears” which are part of the healing process, and larger, deeper tears. While you are reconditioning your skin with the Vaginal Renewal program, your skin may form tiny tears which can release a very small smear of blood. These micro-tears are a normal part of the healing process, and will increase the strength of the skin as they heal.
However, if some skin has become so thin and inflexible that larger tears develop and release larger amounts of blood, you should stop all but the moisturizing and consult your health care provider. There is no advantage to deeper tears, since they will create non-stretchy scar tissue which needs to heal before reconditioning can continue.
It wil also help to use a silicone based lubricant for penetrative sex. Use it on your vulva and on your partner or a toy before penetration.
Muscles.The pelvic floor muscles act as a sling to hold up your abdomen, surround your urethra, vagina and anus, and contract when you have an orgasm. When the pelvic floor muscles are rigid or inflexible, penetration may be painful. This condition is called high tone pelvic floor dysfunction. It can happen when the pelvic floor muscles are unable to relax before penetration. A related but different disorder occurs when an unconscious muscle-tensing reaction develops in response to painful penetration (vaginismus). For more information on increasing the flexibility of your pelvic floor, see the section on Pelvic Floor Strength and Flexibility. If you experience either the inability to relax your pelvic floor, or an involuntary spasm when attempting penetration, you may wish to get a referral to a Pelvic Floor Therapist to help you address this.
Skin Strength and Flexibility
If you are experiencing pain and sometimes bleeding with penetration, we strongly recommend that you do NOT do the internal vibration portion of the Vaginal Renewal program until you have spent four weeks doing the moisturizing and external massage portions, including moisturizing internally as described in the section How to Moisturize. During this time, abstain from (stop) all vaginal penetration. If your body is in the process of healing, the friction of vaginal penetration can tear the skin, making the healing process longer and more difficult.
We encourage you to participate in other types of sex play and intimate touching, but not penetration. This can be frustrating, but slow progress is better than no progress. Your internal tissues need to heal completely and become better moisturized before you attempt penetration again. Every time you do so with bleeding, your body makes a little more non-stretchy scar tissue and has to begin the healing process all over again. So give your vaginal skin tissues a break and allow enough time for complete healing.
It might be tempting to “just do it anyway”, but it’s important to realize that unwanted pain shuts down sexual arousal. Pain can affect not just the immediate experience you’re having, but also your libido, and your ability to relax your muscles to allow penetration in the future. Allowing yourself to experience pain with penetration can also result in vaginismus, a tensing, or guarding reflex of the pelvic floor muscles that makes penetration difficult or impossible, and which is time-consuming to reverse.
After 4-6 weeks of moisturizing and massage, when your skin has healed and you’re ready to try the internal massage again, start out slowly, with the smallest wand. You can take the batteries out of the wand at first to help build confidence that the wand is a comfortable size and does not cause pain or muscle spasms. We recommend that you do this alone the first time so you are in complete control of the experience.
Using plenty of moisturizing lubricant both on your skin and on the wand, insert it vaginally. Just relax for a few minutes, and breathe. When you are comfortable inserting the wand without batteries, go ahead and try with the batteries in, on the lowest setting.
If you are successful with the internal massage, begin doing it once a day. However, if it’s painful or you have bloody discharge, consult your health care provider to rule out other problems. In the meantime, just focus on moisturizing and external massage until you are ready to try again. Remember that the perineal portion of the massage is especially helpful for the flexibility necessary for comfortable penetration. For more information, see the section on Perineal Massage, as well as the section titled Pelvic Floor Strength and Flexibility.
After a month of so of successful, non-painful internal vibrating massage, you could choose to follow the instructions on page 10 for increasing wand size.
When you are ready to attempt vaginal penetration with a partner’s body part or toy, massage lots of moisturizing lubricant both inside your vagina (you can use a needle-less syringe or dropper) and on your vulva. Then, lubricate your partner, finger or toy with a silicone lubricant; this will seal in the moisture, creating a slick barrier to protect your skin from friction. (If you’re using a silicone toy, cover it with an unlubricated condom before applying silicone lubricant to it.)
Pelvic Floor Strength and Flexibility
If you experience comfortable initial penetration (1 1/2 to 2 1/2 inches), but then “run into a wall”, one of two things might be happening. Your pelvic floor may have lost its ability to relax and flex enough to allow penetration (called High Tone Pelvic Floor Dysfunction), or, if you’ve previously experienced painful penetration, your pelvic floor may be contracting involuntarily to prevent penetration (called Vaginismus).
The first step is to verify that your experience of pain is indeed the result of an overly tight or inflexible pelvic floor. There are many conditions easily confused with high tone pelvic floor dysfunction, so self-diagnosis is difficult. If you think you might have either of these conditions, we recommend that you start by seeing your health care provider and/or a pelvic floor Physical Therapist to obtain an accurate diagnosis. Any home-based therapy you attempt is likely to be more effective under the guidance of a pelvic floor physical therapist. For more information, take a look at our article, Pelvic Floor Health for Women.
Where do Kegel exercises fit in?
Properly performed, Kegels help you strengthen and increase flexibility of your pelvic floor muscles. Having a strong pelvic floor will help your orgasms be stronger and longer, and may even increase your libido. A strong pelvic floor also helps keep your pelvic organs where they’re supposed to be, rather than settling down a little lower every year as you get older. And Kegel exercises will help you avoid losing urine when you sneeze, laugh, or exercise.
If penetration is comfortable for you, you should do Kegel exercises every day. To maintain your pelvic floor flexibility at the same time as building strength, be sure to focus on both parts of Kegel exercises: to contract, and to completely relax your muscles.
Many women are advised to only “pull up” the muscles, but no muscle can be healthy if it’s only tightened. Relaxation is the “stretch out” portion of the activity, and comfortable flexibility is a large part of comfortable vaginal penetration. So remember to include the relaxation portion followed by a deep belly breath as well as the contraction portion. For a full description of how to do Kegels properly, (specifically how to build up strength while maintaining flexibility in your pelvic floor), take a look at our article, Pelvic Floor Health for Women.
If you have muscle spasms or pain with penetration even though your vaginal skin is healthy, it is very important for you to increase the flexibility of your pelvic floor muscles before you increase the strength. To strengthen inflexible muscles can lead to more trouble, since the tight muscle will pull against other healthy muscles, possibly causing more damage and pain. We recommend you see a pelvic floor Physical Therapist for advice about your particular situation.
How does it all go together?
Now that you have learned all three parts of the Vaginal Renewal program, go ahead and begin the moisturizing, massage, and vibration to recondition your skin. If it helps, you could highlight the portions of this booklet that pertain to your personal situation for quick reference. If possible, start out doing it once a day. When you reach your own personal goal for how you would like to feel and how much tissue strength and flexibility you want, you could taper off to every other day, and eventually to twice a week. Some women need to do it more, and some less. The way to know is by how you feel, and how quickly your symptoms respond. There are no hard and fast rules here; use your own judgment, and do what seems right for you. If you get stuck or need more information, seek help from us, or from your health care provider.
Other Sexual Health Tips
In addition to the Vaginal Renewal program, in order to maintain the best possible sexual health we recommend you:
Enjoy at least one orgasm per week. Orgasms bring blood flow to your pelvis, which helps keep your tissues strong and thick and your pelvic muscles strong and flexible. It also utilizes your circulatory system and your nervous system, and helps keep everything running smoothly. If you are not as orgasmic as you used to be, the Vaginal Renewal program may help your orgasms become stronger again. If you are not able to orgasm now, or have never been able to, see our Orgasm brochure, or the book The Elusive Orgasm by Vivienne Cass, PhD.
Eat the AWT Good Sex Diet. This is the Mediterranean diet which focuses on antioxidant-rich, colorful food. It includes lots of fruits, vegetables, whole grains, nuts, beans, fish and poultry, but no high-fructose corn syrup sweetened products. Organic food has at least 30% more healthy antioxidants than conventionally grown food, so although it’s more expensive, it’s a much better health value. Chocolate, coffee, tea, honey, wine and beer also contain antioxidants. Cheers!
Exercise to a sweat 30 minutes a day, six days a week This is the best thing you can do for your overall health, and is very likely to increase your libido as well. Studies show that women who exercise until they sweat just before being sexual experience higher levels of sexual arousal than those who don’t. So prime your pump, and get moving.
Stop smoking and avoid smoke from others as well as places where people have smoked. Smoke contains chemicals that directly damage your blood vessels. Damaged blood vessels weaken your skin and lengthen the time it takes to heal from injury. So avoiding smoke in all forms is a major step towards protecting your sexual health.
Floss your teeth. We know this seems silly, but reducing inflammation in your gums cuts down on whole body inflammation. Since body inflammation has a direct negative link to healthy sexual arousal, flossing your teeth daily is one of the easiest ways to keep yourself in tip top shape.