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Painful sex after cancer Resources

Information from Dr. Parastoo Farhady, Kaiser, Northern California  

 
Everyone experiences menopause in their own way. You may have lots of questions. Review our Menopause and Midlife guide (kpdoc.org/menopause) to learn more about:
 
  • Transitioning through the phases of menopause
  • Managing common symptoms
  • Understanding treatment options
  • Staying healthy in midlife
  
 
Menopause Video - https://kpdoc.org/MenopauseEmmi
Menopause and Cancer - https://kpdoc.org/menopauseandcancer
 
 
VULVAR CARE GUIDELINES
 
DO’s
  • Wash your underwear with a mild fragrance-free detergent. Use the extra rinse cycle and do not use fabric softener or dryer sheets.
  • Make sure condoms do not have spermicide, if you use them.
  • Limit use of pads and panty liners to the week of your period. If these products cause irritation, consider trying organic, chemical-free menstrual pads and tampons (such as Natracare) or all-cotton menstrual pads that can be washed (www.gladrags.com). Another option is a reusable menstrual cup, which is made with nonallergenic silicone.
  • Change your underwear after exercising, to limit your exposure to excess moisture and heat.
  • Use a silicone-based personal lubricant for intercourse. Many of the water-based lubricants can cause vaginal irritation.
  • Apply Cera Ve oint, Aquaphor, zinc oxide, Desitin, or A & D ointment if your vulvar skin feels irritated or uncomfortable. Ice packs, a bag of frozen peas, or cool tea bags can also be used.
DON’T’s
  • Do not wash with soap on the vulva if possible. You can use water and gently pat dry. If you must use soap, choose a fragrance-free product formulated for sensitive skin, such as liquid Castille soap, Pears soap (pure glycerin), Aveeno Moisturizing Bar, or Aveeno Skin Relief Body Wash.
  • Do not use a hair dryer to dry your skin.
  • Do not use any skin products containing benzocaine.
  • Do not remove the pubic hair on your labia or mons (the vulva). The pubic hair provides a protective barrier for the sensitive genital skin. Clipping or trimming the hair is fine.
  • Do not use any feminine hygiene sprays or wipes.
  • Do not douche or use any products designed to "acidify" the vagina.
 
 
 
 
Genitourinary Syndrome of Menopause -
Genitourinary Syndrome of Menopause (GSM)
After menopause, the vagina and vulva (skin outside of the vagina) can become thin, sore, and dry due to lack of estrogen hormone. Vaginal tissue can become less elastic and flexible. The small pain nerves in the vulvo-vaginal tissue increase and the vagina may narrow or shorten. Bladder function may also change in several ways after menopause. 
The combined vaginal and bladder issues are referred to as Genitourinary Syndrome of Menopause (GSM). GSM is very common – more than 50% of women will experience some of these symptoms in menopause. GSM is progressive and can worsen if not treated. 
Symptoms of GSM include:
  • Vaginal dryness, itching, and irritation
  • Painful sex (dyspareunia) or tearing/bleeding during sex
  • Vaginal discharge
  • Bladder control issues, including bladder urgency and incontinence
  • Possible urinary tract infections 
Examination alone is often enough to make the diagnosis. You may need additional testing to determine if you also have a vaginal infection. Please let your doctor know if you are experiencing vaginal bleeding after menopause.
Options for Treating GSM
Non-prescription remedies:
Vulva and vaginal moisturizers can provide long-lasting relief for dryness and irritation. Some examples of vaginal moisturizers include: Good Clean Love, BioNourish, RePlens, Hyalo Gyn, Luvena,  K-YLiquibeads, Femani Smooth, Oasis silk, and Coconut oil.
The vulva is the area at the opening of the vagina. It is often thinner and more sensitive in menopause. VMagic can be used to moisturize the vulva and protect from moisture associated with urinary incontinence. It shouldn’t be used with condoms. 
Vaginal lubricants are commonly used to reduce vaginal irritation, dryness, and pain during sexual activity. Apply generously to the genital area shortly before sex, making sure to cover the inner labia, clitoral area, or any parts that feel discomfort during sex. 
Options include:
  • Water-based lubricants are safe with all types of condoms and sex toys. Examples include Almost Naked, Slippery Stuff Gel, Sliquid Organics Natural, and Babelove.
  • Silicone-based lubricants may be less irritating, longer lasting and work well for severe vaginal dryness. Examples include Astroglide X, Femani Smooth, Pink Indulgence, and Oasis Silk. Silicone lubricants can be used with condoms, but they may damage silicone sex toys.
  • Oil-based lubricants have a unique and long-lasting feel that some people prefer. They can be used in combination with water-based lubricants. Examples include vitamin E, coconut, and olive oil. Oil-based lubricants should never be used with latex condoms because they can damage them.
Prescription Remedies:
 
Vaginal estrogen helps the vaginal skin become thicker, produce more lubrication, and reduces the surface nerves that lead to vaginal pain. It can provide relief of genital itching, irritation, and discharge. It can also improve comfort during everyday activities and sex.
 
There are 3 types:
  • Topical cream applied twice a week with your finger or an applicator
  • Vaginal tablet used twice a week
  • Vaginal ring (replaced every 3 months) 
 
Vaginal estrogen is safe, effective, and well-tolerated. It may take 3 months of therapy to achieve the full benefit and must be continued to maintain its effects. It is safe to use long-term.
 
Benefits: Aside from providing relief from vaginal dryness and discomfort, vaginal estrogen may also reduce urinary tract infections, urinary frequency, urgency, and incontinence. 
Risks:  Low-dose vaginal estrogen is a local treatment and does not increase your body’s estrogen as high as full-dose hormone therapy (pills or patch). Therefore it does not carry the same risks for heart disease and breast cancer.
People who’ve had breast, uterine, and ovarian cancer are generally advised to avoid estrogen therapies. However if self-care and other treatments are not providing relief, the benefits of low-dose vaginal estrogen may outweigh the risk. Discuss your options with your gynecologist and oncologist.
Learn more about how to ease menopause symptoms by visiting kpdoc.org/menopause. Or scan the QR code below:
 
 
 
Menopause and Weight Changes - https://kpdoc.org/weightgainmenopause
Understanding Female Sexual Health: https://kpdoc.org/femalesexualhealth
Female Sexual Health After Cancer: https://kpdoc.org/sexualhealthandcancer
 
 
 
 
 
MANAGING MENOPAUSE WITH BREAST CANCER: A Survival Guide
 

Care of the Vulva and Vagina for Women with Breast Cancer as well as other Cancers, Cancer Survivors and Women who are Postmenopausal
Lets start with definitions – what is the vulva and what is the vagina? The vulva is the outside part of the female genitals. It includes the fatty pad covered in hair (mons pubis), the outer lips (labia majora), the clitoris, the inner lips (labia minora) and the vaginal opening. The tissue surrounding the vaginal opening is called the vestibule. The area between the vagina and the anus is the perineum. The vagina is the canal that leads from the outside to the cervix, the opening of the womb (uterus).
 

 
Menopause, whether “natural”, or caused by surgery (removal of ovaries) or medications like chemotherapy, is a state of low estrogen, and low estrogen causes lots of issues for the vulva, vagina and bladder. The technical term is "Genitourinary syndrome of menopause" or "vaginal atrophy", and it is commonly under diagnosed and under treated in all women. While it is not a dangerous problem, it can severely impact a woman's quality of life!

What are the symptoms of low estrogen of the vulva and vagina?
Symptoms you may notice include vaginal or vulvar dryness, itching, irritation, burning, tearing of the skin, recurrent bladder infections, burning when peeing, peeing frequently, leaking urine and/or stool, dryness and pain with and after sex and difficulty with penetration.

Why is it worse for breast cancer and other cancer survivors?
Cancer survivors can experience symptoms earlier and more intensely because of an abrupt drop in estrogen caused by a medically induced early menopause (from chemotherapy drugs), surgically induced early menopause (if ovaries are removed as part of treatment) and because many of the medical treatments offered for breast cancer survivors including GnRH agonists (lupron), aromotase inhibitors (letrozole, arimidex) and SERMS (tamoxifen) are designed to get rid of all traces of estrogen in the body to decrease the risk or recurrence, and it is estrogen that keeps you moist!

So, what happens to the vagina and vulva with menopause?
The vagina shrinks, tightens, and loses all of the folds that allow expansion to accommodate a penis, toy or baby's head! Blood flow to the clitoris, vagina and vulva becomes more sluggish - so arousal can also take a lot more time and masturbation or foreplay can be irritating because the skin on the vulva thins and can be torn easily. The muscles in and around this area also thin and weaken, so that the support of the bladder, uterus and rectum can be less, leading to worsening prolapse (dropping of the bladder and/or uterus) and worsening leaking of urine or even stool. The distance between the anus and urethra gets smaller, increasing the risk of infections especially of the bladder. The pH of the vagina changes so that discharge can look and smell differently because different bacteria can now grow in the vagina, and the discharge is a different viscosity and can be less “slippery” with sex.

Is there anything I can do to prevent this from happening?
There is nothing that is going to prevent these things from happening altogether! However, there are things you can do that can really minimize the changes and prevent them impacting your quality of life! But like everything worth having – there is NO easy fix, NO instant gratification AND it is going to take effort and work on your part!
Where do I start?
The two most important principles are TLC (and that means what you think it does – tender, loving care!) and using the vagina.

Lets talk about TLC first!
The main goals are gentle care and cleaning, avoiding over cleaning, avoiding all irritants, hydrating and moisturizing.
The first thing you need to do is to think about everything that comes in contact with your vulva and vagina! I mean it – everything! The idea is to minimize contact with irritants! So soaps, laundry detergents, panty liners or pads, over the counter feminine hygiene products, underwear and other clothing, wipes, lubricants, shaving creams and so on.
Now I know what you are going to say (or think)! That you have used that soap, that laundry detergent, or whatever, for years, and have never had a problem before! Well that might be true, but NOW you can’t use them! Now, with menopausal changes, any of these irritating products, can tip the scales in a major way – and we want to prevent that! The idea is to remove all irritants that COULD tip the balance to really give you a problem that impacts your life – so lets get rid of all of those products to prevent that from happening!
Remove All Irritants: Please avoid (if possible):
  • Irritating soaps (colored, perfumed, liquid and antibacterial)
  • Bubble baths
  • Hot tubs (heat and chemicals)
  • Chlorinated pools
  • Daily use of pantyliners
  • Sanitary napkins/pads
  • Perfumed products (including Dove for sensitive skin)
  • Disposable wipes, including baby wipes (if you must use them please rinse out with water first as most contain alcohol)
  • Feminine deodorant products
  • Over the counter yeast treatments such as Monistat or Vagisil
  • Tight and synthetic clothing
  • Over cleaning

Lets get specific:
Soaps: can be irritating and drying. I would encourage no soap, but if you must, you should use a bar soap ONLY (no liquid soaps – even the “natural ones” have irritating products that makes it a liquid) with no colours or perfumes and NOT antibacterial! Anything that burns when it touches the skin needs to be rinsed off immediately and not used again.
Suggestions for soap to use: Dove unscented (NB. Not Dove for sensitive skin), Pears, Bronners Baby bar soap, Cetaphil gently cleaning bar
Laundry detergents: no colours or perfumes! Every brand now has a scent free/colour free option – so get one of those. No dryer sheets or softeners on your underwear – so you may need to line dry your underwear
Panty liners: many women need to use pads and panty liners due to urinary leaking, and they can be very irritating to the skin of the vulva. Nothing is that white naturally - so lots of chemicals including bleach need to go into products like pads and panty liners. There are more “natural” and cotton/organic products widely available – so try those. Also please avoid period pads/pantyliners - those made for urinary leaking wick away moisture better than period pads. Also, there are a lot of reuseable underwear products designed to prevent the need for pads which you could try such as:
Bambody (bamboo fabric),
Modibody (merino wool and bamboo),
Knix (cotton),
Speaxs (polyester). I recommend trying to stay away from polyester if you can!
Over the counter products/feminine hygiene products: Products such as Summers Eve, Vagisil and Monistat are NOT meant for postmenopausal skin. They are harsh and can even cause chemical burns. Postmenopausal women are not at the same risk for yeast infections or BV (bacterial vaginosis) as they were when they were younger - although women with diabetes or those who have been recently treated with antibiotics can have yeast/BV, but then we would treat you with a pill and not an over-the-counter cream! Itch, in a postmenopausal woman is most likely related to dryness, so an over-the-counter yeast treatment is NOT recommended. Don't self-diagnose! If you are having symptoms you are concerned about, make an appointment to be seen and diagnosed so that you can be treated appropriately.
Shaving or Waxing: Don’t do it! TV shows and books make it seem as though it is more fun, hygenic and sexy to take off your hair. Hair is there for a reason! It protects the sensitive skin of the vulva, as well as the vagina, urethra and bladder, and removing hair makes you more vulnerable to infections of the skin, bladder and vagina, dryness and irritation. Not to mention the process for hair removal can be very irritating. Trim if you must, but think of how vulnerable our eyes become without eyelashes!　
Clothing: Think well fitted, ventilated and natural fibers next to your skin - no tight clothing (sorry skinny jeans, girdles/support wear and hose) and no thongs! Do I need to spell it out – tight clothing and thongs are abrasive and one more irritant we don’t need! Not to mention I think of thongs as ladders for bacteria from the anus to the vagina and bladder ! Don’t sit around in wet bathing suits! After being in a pool or hot tub, rinse off the chlorine and change into a dry bathing suit if you are going to hang out by the pool. For sports wear – choose performance fabrics that “wick away” moisture and sweat and change out of them after activity. Consider no underwear at night for ventilation
Wipes: Most of them contain alcohol (even the ones for babies and sensitive skin) and alcohol is drying. So, my preference is not to use them at all, but if you must use them, then please rinse them out with water before using them on your skin
Urinary or Stool Incontinence or Diarrhea: Urine and loose stool are exceptionally irritating to the vulva and vagina (they are very acidic). I recommend using a water bottle with room temperature water to rinse the urine and stool off after using the bathroom (or use a bidet function toilet or sitz bath for soak). Using a barrier on the skin such as VMagic or zinc oxide (diaper rash cream) after rinsing and patting dry will protect the skin.
  • Avoid daily use of pantyliners/pads
  • Period pantyliner/pads are not for urinary incontinence, they do not keep urine away from the skin of the vulva. There are now many products for leaking urine that are discrete and no bigger than a pad. There are more “natural” and cotton/organic products widely available – so try those.
  • Try reuseable underwear products designed to prevent the need for pantyliners/pads such as: Bambody (bamboo fabric), Modibody (merino wool and bamboo), Knix (cotton), Speaxs (polyester). I recommend trying to stay away from polyester if you can!
  • Use barrier creams as needed such as VMagic, Butt Paste, Desitin or any other zinc oxide product (diaper rash cream) – just a thin layer applied over the vulva or around the anus
  • For stool incontinence - take 20mg fiber every day, also take 1/2-1 tablet of Immodium every day (start with 1/2 tablet)
　
Pamper in a Good Way
To Cleanse: did you know that the vagina is self cleaning and doesn’t need to be cleaned by you? When you wash the vulva:
  • Be gentle
  • Bare hands only – no face cloths, sponges or scrubbing
  • Luke warm water – not hot water
  • Consider the following soaps: Dove unscented (NB not Dove for sensitive skin), Cetaphil cleanser, Albolene Moisturizing cleanser
  • Consider NO soap if you are having any symptoms such as itch or irrtiation
  • If you bathe more than once a day, use soap only once
  • Pat area dry. Do not rub. No hair dryer (unless cool setting)
  • No vaginal cleansing/douching – this removes the normal protective coating and changes the ecological balance and can result in irritation, burning, stinging and infection
  • Minimize shaving and waxing to bikini line only – better yet, only trim!
  • Consider always using a water bottle (room temperature) to rinse after urinating to wash away the irritating uric acid or after a bowel movement especially if you have loose stool or diarrhea
　
Lets get specific:
Soaking and moisturizing for the vulva: When the skin is dry, irritated or cracked it must be hydrated and it is best done by soaking in clear, warm water – you can use a tub or sitz bath. Sitz baths that can sit on the rim of your toilet can be purchased at most local pharmacies. You fill the central part with water from a jug. You can add a tablespoon of baking soda or salt if desired – but plain water is great! Soak for 5-15 minutes, twice or three times daily, or as needed including after sex. If a tub bath or sitz bath is not possible, use a warm and wet compress, soaking the area with a soft cotton cloth, or handheld shower head with a gentle spray, or bidet function on your toilet. Pat off excess water and apply a balm to hold moisture in the skin.

Moisturize the Vulva
Moisturize the areas of the vulva where you feel dry, irritated or any discomfort! You can include the area around and including the anus.
I LOVE VMagic!!! It is an oil and beeswax-based product and it literally can be magic! You can find it online! You can also use Vaseline or Cetaphil healing ointment – both are petroleum based products. Do NOT use creams – creams have very irritating ingredients. Whatever you choose, apply a thin layer to the vulva. And use it daily even if you are are not soaking – put it on after a shower – think of it like putting moisturizer on your hands!

Moisturize the Vagina
Vaginal moisturizers trap moisture in the cell layers of the vagina, and studies tell us they can improve the symptoms of vaginal dryness and increase comfort. In most cases they are used twice a week, but can be used more frequently and often need to be used daily especially when undergoing chemotherapy or are using an aromatase inhibitor. They need to be used consistently – not occasionally when you remember – week in and week out! I suggest applying at night so that the product will coat the entire vagina and stay in place overnight. Many women freeze cubes (or other shapes) of coconut oil and insert daily or nightly. Below are some over the counter products that you can try:
Revaree: hyaluronic acid insert
Replens
Hyalo GYN
Luvena 　
NOTE: Creams and lotions are too drying and expose you to too many potential irritants. Lotions also contain alcohol or propylene glycol which burns. Please gently remove and do not reapply any product that burns as this is an indication that the product is causing more irritation!

What about prescription medications/treatment for the vulva and vagina?
Lidocaine – topical anesthetic that can be applied to the opening of the vagina prior to sex or penetration and can make penetration less uncomfortable
Vaginal Estrogen (estradiol) - has minimal absorption into the blood stream and we do occasionally consider its use in breast cancer survivors after consultation with your oncologist if we don't get relief from nonhormonal moisturizers - although not usually if you are on an aromatase inhibitor such as Anastrazole or Letrozole! We prefer the ring, ovule or tablet in breast cancer survivors as they are lower and more controlled dosing, and we sometimes do estrogen levels if we decide to go this route
DHEAS (Prastarone) - daily vaginal dosing does not seem to raise blood levels of testosterone or estrogen but there are no real safety data on this product in breast cancer survivors
Testosterone – no data saying it can be helpful, and there are concerns about side effects including breast cancer
Osmiphene – an oral medication that is a SERM (like tamoxifen) hasn’t be studied enough in breast cancer survivors so is not recommended
Vaginal lasers – like the Mona Lisa have some studies showing benefits for the postmenopausal vagina, but are not FDA approved for this use

Sex and Libido (sex drive) – Taking care of the Vagina!
For most women in the midst of a new breast cancer diagnosis, sex and libido may not seem pressing issues. This is all about quality of life, and right now it may not seem super important – but it may become an issue for you and your sexual partner(s) in the future. Prevention is better than the cure – keeping your vagina useable is easier than trying to rehabilitate it!
There can be multiple issues with intimacy, with menopause and/or breast cancer: both related to sex drive and to the physical part of intimacy (being able to get aroused, actually using the vagina with penetration (if desired) and the ability to actually have an orgasm).

Libido or sex drive
The first thing I will say, is that the sex drive of a woman is NOT the same thing as the sex drive of a man (except maybe in the first few months of a new relationship). A man can be doing the dishes and feel turned on suddenly. A woman is doing the dishes and is definitely NOT going to feel turned on at all! She is too busy feeling annoyed that she is doing the dishes again, that the house is a mess, that work is stressful, that she has to help her kids with their homework etc. Sex drive for women is all tied up in everything else – how she feels about herself and her body, how annoying her partner is or how much he or she is helping her, how much stress she is under and – not to mention BREAST CANCER!!!!.
For women, desire most often starts once you are IN the sexual encounter – not before. If you are waiting to feel turned on before having sex, then it's not going to happen. So, for women who think sex is important - both for themselves and their healthy relationship - then you might have to think about sex like homework! I know that doesn‘t sound fun – or sexy - but it’s the truth! Sex may not be on the top of your list of things you want to do, but usually most women who take this approach are happy both during and after the encounter because it's good for you – it releases endorphins and improves your mood - it's good for your relationship AND it’s good for your vagina (preventing it from shriveling up)!

What about medications to help with libido?
There is no easy medical solution for libido – especially for women who are postmenopausal and breast cancer survivors.
Testosterone has been found to be helpful for libido in some postmenopausal women, but it is not FDA approved in the US, it is a controlled substance and has significant adverse effects including unwanted hair growth, acne, possible cardiovascular issues and a possible increased risk of breast cancer
Flibanserin (Addyi ®)– is FDA approved medication for libido issues but ONLY in women who are NOT menopausal – and it has significant side effects including low blood pressure and fainting and can’t be used if you drink any alcohol
Bremelanotide (Vyleesi®) – is injected before sex, is also for premenopausal women and has side effects like headache and vomiting
Over the counter options: Recommending over the counter options is complicated because there are very limited studies and they are not FDA regulated.
Go to Memorial Sloan Kettering site Herb-Drug Interactions in Cancer Care | Memorial Sloan Kettering Cancer Center (mskcc.org) for information on any supplements in the setting of cancer treatment
L-arginine/citrulline – amino acid supplement that supposedly helps with blood flow/arousal
Tribulus 7.5mg daily
MACA 1.5-3.5mg daily
Red ginseng 3 g daily – thought to be estrogenic so not recommended for those with breast cancer
Fenugreek 600mg daily (don’t take if using blood thinner)
Saffron 30mg daily if for those on antidepressant caused libido issue
Gingko biloba – 209 g daily
ArginMax – contains multiple products including L-arginine, ginseng, gingko- not recommended for breast cancer patients due to ginseng
Zestra – topical application – wash off immediately if it burns
 
Physical Issues with Sex
So what physical issues are we talking about?
  1. The vagina loses its folds and shrinks and tightens with menopause (and chemo) and if you are not having any sort of penetration (penis or toys) on a regular basis, it can be hard to do those things again. I have seen women who have not had sex for years with vaginas that barely accommodate a finger. So you really do need to use the vagina to prevent that from happening.
  1. Blood flow gets sluggish so it can take longer to get aroused and have an orgasm.
  1. The muscle around the vagina thins and gets weaker increasing prolapse problems with the bladder, uterus and rectum
  1. The skin on the vulva and the vaginal lining thins and can tear with touching and sex!
Knowing all of this means we can have a strategy to build resiliency of the vagina and keep it useable! The bottom line – what you need to do regularly (not occasionally when you remember):
  1. Vulvar care including vulvar and vaginal moisturizers
  1. Frequent penetration with lubrication
  1. Lots of foreplay with lubrication
  1. Lots of lubrication

Penetration
So I recommend “penetration” 2-3 times a week to keep the vagina useable. That can be sex with a partner or using toys. Most women who masturbate only stimulate their clitoris to have an orgasm. That is because most women do not need penetration to orgasm. However, we are talking about a strategy for keeping the vagina useable and resilient – and that means penetration.

Buy a Vibrator!
You may want to buy a vibrator, but might feel uncomfortable or unsure of how to go about selecting one. It can feel intimidating, but there is a lot of help out there. You can visit your local sex shop – Pleasures of the Heart in downtown San Rafael, and Good Vibrations with locations around the Bay area have helpful and friendly staff who are sex educators that can help guide you. Or you can shop online at places like goodvibes.com, drugstore.com or amazon.com! I like the following brands: Lelo, We-Vibe and Love Honey (all relatively expensive) and Pleasure Works, California Exotic and Aura (more budget friendly).. I recommend the rabbit style of vibrators- they literally look like a bunny and the larger portion goes into the vagina, and the shorter portion stimulates the clitoris – don’t forget the lube!

Vaginal Dilators
If you haven’t had any sort of penetration for a while you may need to use dilators to get back some capacity of the vagina
Vaginal dilators are smooth cylinder-shaped objects in various sizes that are used to stretch the pelvic floor muscles and increase the capacity of the vagina . They usually come in packs of 4 to 6 and can be simple or fancy (think vibrations, apps etc). Vibrations can actually be helpful by encouraging tense muscles to relax
How to use dilators
Follow these steps:
  1. Lie down with your knees bent and slightly apart. Lubricate the smallest dilator with an oil, water or silicone-based lubricant (if your dilators are made out of silicone then water-based lubricants are preferred).
  2. Slowly insert the lubricated dilator in the vagina as far as it can go without causing any pain, although leave at least 1 to 2 inches outside of your body so you can easily remove it. You can leave it in place for 5 to 10 minutes.
  3. Use can use the vibration control to help your muscles relax and soothe nerve pain if you have dilators that vibrate. You can also try using vibration for 1 to 2 minutes or longer for 5 to 10 minutes.
  4. Try the next larger size dilator if you have no discomfort for a week with the smaller size. To begin, dilate for a few minutes with the smaller size then change to the next size dilator for the remainder of the session. When you can do this for several sessions without pain, you are ready to switch to the next size dilator. Everyone progresses at a different rate and it may take several weeks to use the next size dilator.
If you have pain at the vaginal opening, you can apply some topical lidocaine to the painful area for 5 to 10 minutes before dilating – see below
If you are seeing a pelvic floor physical therapist, we recommend that you take your dilators to an appointment so they can make sure you are using the dilators correctly.
A small amount of spotting is normal when you first start using the dilators. If the spotting continues past 2 weeks, or if you have heavy bleeding or pain when dilating or afterwards, stop using the dilators and follow up with your doctor.
Where to buy dilators
For most women, a set with 4 vaginal dilators is sufficient. You can buy simple silicone dilators including The Dr. Laura Berman Dilator Set (with vibrating settings) online. Milliforher.com offers a very fancy and expensive option which has vibrating settings and is an all-in-one option with a digital display
Lubrication
It is important to use a lubricant for any penetration as well as for “touching” the vulva. The skin of the vulva and the vaginal lining thins and can tear easily without a lubricant. You may have to reapply during sex especially if your partner has a medical condition that means he takes longer to ejaculate. Prolonged penetration in a dry environment can cause small abrasions/tears that can make symptoms worse - think friction. I prefer silicone and oil-based lubricants, although oil should NOT be used if using a condom! Read the ingredients of the lube - and please try to avoid lubricants that have any ingredient that ends with an –ol, which means alcohol and can cause burning. A good rule of thumb is that if it can go in your mouth it can go in the vagina, so oils from the kitchen are ok! And again, if something causes burning gently remove it and don't apply it again!
Suggestions for lubricants: Astroglide, Replens, Probe, Pjur Women, Slippery Stuff, Sylk
Can also use olive oil, uncooked egg whites, vegetable oil, coconut oil, crisco,Vitamin E oil,
Important Notes:
Avoid parabens
Glycols and glycerin above 9.9% can be irritating
Water based lubricants often have alcohol and can be drying especially for postmenopausal women
Silicone based lubricants can damage silicone based toys
Oils should not be used with condoms
Other treatment modalities
 
Topical anesthetic
You could use a topical anesthetic like lidocaine prior to any penetration (masturbation, dilators or sex) to make it more comfortable. It is applied for 3-5 minutes prior to sex and can initially burn
 
Pelvic floor Physical Therapy
Can be very helpful in treating conditions of the pelvic floor that lead to pain with sex and prolapse including menopausal changes as well as changes due to chemotherapy. It can be very helpful as an adjunct to vaginal dilator use. Kaiser has some amazing and experienced pelvic floor physical therapists
 
After sex or penetration with vibrators or dilators
Postmenopausal women often complain of some soreness, stinging, burning or discomfort after any form of penetration. I recommend soaking either after sex or the next day to help with healing. Use vulvar and vaginal moisturizers and consider cool gel packs - (soft plastic picnic freezer packs), keep in resealable plastic bag in refrigerator, (NOT in freezer) and apply to area after sex for 10 minutes or so
 
For Itch
Itch is the primary symptom related to low estrogen and signals dryness. But it can also be a symptom of an underlying problem, like a skin condition or allergic reaction. AND, the more you itch the itchier you will feel. So, it is really important to break the “itch/scratch” cycle.
  • Cool gel pack (soft plastic picnic freezer packs), keep in resealable plastic bag in refrigerator, (NOT in freezer) and apply to area as needed
  • Plain, cold yogurt on the vulva can be soothing
  • Daily antihistamine such as Zyrtec or Claritin
  • Corticosteroid ointments (not creams) if prescribed
  • Oral medications such as benadryl(25-50mg) or hydroxyzine at night (if prescribed)
NOTE: chopped ice or frozen vegetables in plastic bags can cause frostbite and further injury
If none of these strategies work please come in and be seen so we can make sure there is nothing else going on
 
 
 
Mindfulness Resources for Sexual Health
 
For many people, our minds are our greatest sexual organ.  Research has shown that mindfulness can improve physical, emotional and sexual function.  I have collated some information below, including articles, expert websites, classes and courses offered here at Kaiser as well as outside offerings, and podcasts.  I have also included information on how to access the CALM app at no cost to Kaiser members, as well as our mental health resources.
 
Exercises:
7 Ways To Train Your Mind and Body For Better Sex, According to Experts (Inverse)
 
A Neuroscientist's Top 8 Mental Hacks To Help You Have Better Sex Tonight (Well + Good):
 
Exercises For Better Sex (WebMD):
 
Sensate Focus: Getting Out of Your Head and Into Your Body During Sex (GoodTherapy.org):
 
5 Tips for a More Mindful Sensual Experience (Gaia):
 
6 Tips for Being More Mindful and Present During Sex (Psychcentral):
 
Podcasts:
Sex and Psychology Podcast with Dr. Justin Lehmiller
            Episode: Better Sex Through Mindfulness with Dr. Lori Brotto
Foreplay Radio
10% Happier Podcast
Mind Blowing Sex- How Mindfulness Can Help with Libido and Desire
 
 
Resources from the Experts on Mindfulness and Sexual and Emotional Health:
Better Sex Through Mindfulness (2018 Greystone Books)
The Better Sex Through Mindfulness Workbook (2022 Greystone Books)
 
https://www.debunkingdesire.com/report- Social Media Report to Debunk Myths and Raise Awareness of Low Sexual Desire in Women  #debunkingdesire
https://www.youtube.com/watch?v=MsXs7_wsMBw- Understanding a Woman's Sexual Desire and Arousal
 
 
The Gottman Institute- Dr. Joel and Julie Gottman
Gottman, John and Julie, (2022) "The Love Prescription." Penguin Books
 
Dr. Esther Perel
How to Build Sexual Desire
 
Sexual Health and Mindfulness Courses/ Programs:
Kaiser Northern California has online courses:
Savvy Sex Class  Please Call (925) 906-2114 to schedule
Mindfulness Meditation Course- through your local Health Education Department at KP
 
Outside of Kaiser:
The Art of Living Institute: https://www.artofliving.org/us-en
Self Compassion with Dr. Kristin Neff and Dr. Chris Germer:  https://self-compassion.org/
MBSR (Mindfulness Based Stress Reduction) 8 Week Certificate Course by Dr. Jon Kabat-Zinn
Free online MBSR Training Course: https://palousemindfulness.com/
 
Articles:
Minds Over Matter: Practicing Sexual Mindfulness (Mayo Clinic): https://mcpress.mayoclinic.org/living-well/mind-over-matter-practicing-sexual-mindfulness/
 
How To Be More Present During Sex (Teen Health Source):
 
Hope for a Satisfying Sex Life: Overcoming Shame, Stigma and Bothersome Symptoms (Mayo Clinic):
 
What's Sex Got To Do With Mindfulness? (Mindful.org): https://www.mindful.org/whats-sex-got-to-do-with-mindfulness/
 
Mindful Sex (Headspace):
 
How To Use Your Brain to Have Better Sex (Oprah Daily):
 
Mindful Sex: A Guide to Becoming Fully Present Sexually (Center For Growth):
 
9 Ways Mindfulness Practice Can Improve Your Sex Life (Psychology Today):
 
The Role of Sexual Mindfulness In Sexual Wellbeing (NIH article)
 
Want Better Sex?  Start with the Mind-Body Connection (Healthline):
 
Why Sex Therapists Swear by Sensate Focus: The Mindful Touching Technique that Enhances Your Sex Life (Business Insider):
https://www.insider.com/guides/health/sex-relationships/sensate-focus
 
 
Emotional Wellbeing at Kaiser:
Everyone can benefit from caring for their emotional well-being and mental health. We offer a wide range of resources to help you:
 
  • Manage or prevent mental health symptoms and support your emotional well-being and overall health.
  • Navigate life's changes and challenges and bounce back after tough times.
 
Our self-care information, digital tools, classes, and wellness coaching services can be used alone or together with clinical care.
 
Learn More
 
  • Tame Stress – Learn about stress, its effects, and positive coping skills to help you manage it.
 
  • Manage Depression – Learn about symptoms and treatment for depression. Watch this video to hear stories from others about depression and recovery.
 
  • Overcome Anxiety – Learn about symptoms and treatments for anxiety.
 
  • Improve Sleep – Learn about lifestyle changes and other treatments for insomnia. Watch this 20-minute video.
 
 
Use Our Digital Tools (Apps)
 
  • myStrength – The myStrength app is a cognitive behavioral therapy (thought and behavior change) tool. It's uniquely designed to provide personal inspiration, build resilience, and strengthen skills for emotional wellness.
 
  • Calm – The popular Calm app helps improve sleep, reduce stress, and manage anxiety. 
 
  • Ginger – The Ginger app provides 24/7 access to private, one-on-one, text-based emotional support from behavioral health coaches. Kaiser Permanente members ages 18 and older can register on kp.org to access one 90-day subscription every 365 days. (The Ginger app isn't yet available to Medi-Cal members.)
 
Interested in myStrength, Calm, or Ginger? Access these apps here. 
 
 
 
Access Clinical Care
 
If your mental health symptoms are more severe, email your doctor or call your local Mental Health Department. We offer many options for members with mental health, emotional, and addiction issues. A clinician will assess your needs and discuss treatment options to help you find care that works for you. You don't need a referral from your doctor to access our mental health services. Millions of people seek mental health services every year.
 
If you think you have a medical or psychiatric emergency, call 911 or go to the nearest hospital.
 
Find Other Resources
 
 
For Parents
Feeling overwhelmed and need to talk now? Call 1-800-4-A-CHILD (1-800-422-4453) or visit our website. 
 
Alcohol and Substance Use
Learn about alcohol use and dependency.
Check out Alcoholics Anonymous for more information or to find a local meeting.
 
Learn about substance use and dependency.
Check out Narcotics Anonymous for more information or to find a local meeting.





Other Resources I found helpful during this journey:
My Breast Choice
Website: www.mybreastchoiceshow.com
YouTube: www.youtube.com/user/MyBreastChoice/videos


BreastCancer.org www.breastcancer.org
Susan G. Koman ww5.komen.org
Stereotactic Breast Biopsy Info radiologyinfo.org
Mayo Clinic Breast Cancer Info www.mayoclinic.org


Charitable Organizations
Tyler Robinson Foundation www.trf.org



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