Messy Midlife

Sexual Health As We Age with Pelvic PT Cindy Furey

• Season 1 • Episode 36

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Today we have Cindy back for yet another important episode all about sexual health. 

We talk about:

  • Hormone changes to tissue and structure of the genitals
  • The importance of moisturizing our vagina (its as important as moisturizing our skin)
  • The importance of early intervention to maintain flexibility of the vaginal canal/tissues and prevent atrophy
  • The role of hormones in the health of vaginal tissue
  • The fears many women have when it comes to using hormone support
  • The ideal time to implement a vaginal care protocol, and some things you can do if you feel like you are behind on this
  • The importance of understanding your arousal and sexual response languages
  • The impact of stress on both sexual desire and pelvic floor function and some things you can do to help with it
  • Ways outside of sex that you can tell if you have vaginal dryness (and the times you might think you have an infection but don't)
  • How often you should have sex to maintain sexual health and pelvic floor integrity
  • The changes in orgasm with perimenopause, the role orgasm plays in tissue and mental health, and the hope in improving it

Cindy's favorite products: 

Bonafide: Revaree vaginal moisturizer
Good Clean Love
Intimate Rose
Uqora Urinary Health
The Pelvic People

Find Cindy: 

Comprehensive Therapy Services, Inc.
https://www.comprehensivetherapy.com

Socials: @comprehensivetherapyservices

Find other Pelvic PTS

Episodes on hormone replacement: 

Hormone Replacement Therapy in Perimenopause & Menopause

Non-Hormone Support in Perimenopause and Menopause


Chapters
00:00 Understanding Sexual Health in Midlife
02:49 The Impact of Hormones on Sexual Function
05:28 The Importance of Early Intervention
08:07 Exploring Treatment Options for Sexual Health
11:06 Addressing Stigma and Fear Around Hormone Therapy
13:48 The Role of Communication in Sexual Relationships
16:31 The Connection Between Stress and Sexual Desire
19:09 Body Awareness and Sexual Health
22:08 The Importance of Foreplay and Arousal
24:44 Navigating Conversations About Sexual Health
31:43 Exploring Hormonal Support and Vaginal Health
36:10 Understanding Vaginal Dryness and Its Indicators
41:06 Maintaining Sexual Health and Frequency
45:21 The Role of Orgasm in Sexual Health
50:38 Hope for Improved Sexual Response
56:56 Final Thoughts on Sexual Health

If our messy is your kind of messy, we would love for you to rate, review and follow or subscribe wherever you get your podcasts. 

We would also love to know what is on your mind. If you were to join us, what would we be talking about? Email us at messymidlifepodcast@gmail.com or message us on Instagram or TikTok @messymidlifepodcast.


SPEAKER_03

Real women. Real talk.

SPEAKER_02

Real messy.

SPEAKER_03

This is messy midlife. Hi everybody and welcome back to Messy Midlife. Good morning, ladies.

SPEAKER_05

Good morning.

SPEAKER_03

And good morning, Cindy. Thank you so much for coming to join us yet again so that we can have probably the most important conversation. And that's the one that's on everybody's mind after we talked about the necessary stuff and the stuff that does affect our life and our day-to-day. But we always think about sex when we think about perimenopause and menopause and the changes that come with sexual health, sexual desire, all of that. And it's so wrapped up in many ways with our pelvic floor. And so we thought we should come and have another conversation with you about sexual health as you are aging and going into perimenopause and the role that the pelvic floor plays in all of that. So thanks for coming back to chat yet again.

SPEAKER_04

Yeah, no problem. Thanks for having me.

SPEAKER_03

So before we got started recording, we were sort of joking around about a couple of things. And what one of us said, might have even been me, I don't even remember. One of us said, What is sex at at this age? Oh, Lisa, I think you were the one that said what is sex. And everybody agreed. Yes. And so I mean, let's just let's just start. What do we need to know? What do you think is the most important stuff for us to know or think about as we are heading into perimenopause and menopause when it comes to sexual health?

SPEAKER_04

Well, as a pelvic PT, I hear a lot of stories. Women come to me when things aren't working. But let's let's just say for a lot of women, things are working well. You know, they have a healthy relationship, a healthy sex life, their hormones haven't totally tanked, or they have support along the way. So um for women, it's it is a lot about hormones. I mean, you know, and without those hormones, things change. Things change in the vulva uh and in the musculature of the pelvic floor. So the vulva, vestibule, vagina, all very estrogen dependent, right? But the tissues also and the muscles are definitely testosterone dependent. So a lot of people focus on the lack of estrogen, which changes a lot of things. But we do have to remember the lack of testosterone changes things too. As uh a pelvic PT, I do a lot of like a ridiculous amount of education on what's going on with their pelvic floor. And it usually starts because they did have a healthy sex life and now they don't, usually because of pain. Deestrogenization, our vulgar tissue dries, atrophies, gets very thin, it can get very red. The biome, that healthy flora can also get off. So uh when that's off kilter, then some women are going back and forth between yeast bacteria, yeast bacteria. They're in the gynecologist, you know, every week. Like what's going on down there? Things don't feel right. They're either itchy, dry, on fire, tearing, bleeding. But a lot of that has to do with the deestrogenization and lack of testosterone in the tissue. So the tissue itself is actually also testosterone dependent. So I cannot prescribe hormones. That's not my thing. But what I usually say is, hey, you know, you need to talk to your gynecologist about these things. And then for a lot of women, it, you know, their gynecologist has mentioned things that, hey, you know, we can start on HRTs or we can start with, you know, vaginal suppositories. But sometimes the physicians don't have um the time to explain why, you know, and why that can be helpful. If the tissue dries, it can tear, you can get like little paper cuts, or it can just be rubbed raw easily. Um, and again, I can't prescribe estrogen or testosterone, but I can recommend that women do that and supplement with the appropriate vaginal moisturizers and the right lubricant. And I teach women a lot about the difference between moisturizers and lubricants. And here we are spending all this money moisturizing, we're putting the hyaluronic acid all over our face, we're we're layering on all the serums and the creams all over our beautiful faces, and we're rubbing lotion all over our hands. But what are we doing for our poor vagina? We are ignoring it and hoping it'll all just go away, or we won't have to deal with it anymore.

SPEAKER_03

Yeah, just complaining that it's dry and tearing and uncomfortable and all the different things that people say about their vagina and then just leaving it. Yeah.

SPEAKER_04

Well, yeah, and and then with the testosterone tanking, our sex drive may go down, and then it's like it just gives us kind of an excuse not to want it to make it a priority, right? If your libido is lower because your testosterone and estrogen have tanked, then are you really just gonna immediately run to the gynecologist? Or you know, do you hope that it just goes away? You know, you hope that it all just gets better, that it's probably just a little bacter vaginitis or a little bacteria, and it'll all go away and get better. But then women wait and wait and wait, and it doesn't get better, and things can definitely get worse.

SPEAKER_02

That's such an important topic that is great for what we're talking about today, and generally so powerful for us in midlife is that used to work really well. I I really appreciated how if I waited with most things physically, definitely my body was like, all right, yeah, I remember how to do this again. And it's it was fine. And so, you know, now we're at a stage where that needs to be revisited because it's not like that anymore. And we I know I certainly had a tendency to just let's just let's just wait and see. And now I think that leads to a lot of unnecessary suffering, which is what I think you're getting at here.

SPEAKER_04

Yes, yes, and there's you know, early treatment, early intervention, help assistance, you know, can make a huge difference. But the longer women wait, the worse the consequences are. One thing that I've seen with some women is that they've waited and waited, and not only has the tissue atrophied, but sometimes the vaginal tissue gets stenotic, meaning that canal that's a circle, you know, it's supposed to be this nice tube, flexible tube, starts to turn in on itself. And it can happen at any length. We can have stenosis right at the vestibule, the opening of the vaginal canal, or it could be deep. And once the stenosis starts and is significant, it takes work, a lot more work, to get that flexibility back. And it's really interesting because if people complain, so with painful sex, there's there's pain at the opening, superficial dysperonia, pain with insertion. But sometimes it's the deep stuff, right? No, opening is fine. My partner can get in, but but then it's like there's a a wall in there. And I've definitely had quite a few people who have gone to their doctor and the doctor does a pelvic exam, they're like, nope, everything's fine. You know, they put one finger in, they're feeling for the muscles, and sometimes the muscles are fine. But if you put one finger through the middle of a hole, you're just gonna, it's gonna be a you can miss the stenosis. So I usually, as long as the superficial tissue can tolerate the stretch, use two fingers, and I'm I'm really sleuthing. I I'm really looking for the source. So sometimes you can blame the muscles, sometimes just out of pain, we pull in uh and react to the pain because pain is supposed to be protective response, so our muscles really clench. But sometimes the muscles are fine, but it's the stomatic tissue inside that you can really only feel if you're you're going in deep with doing a two-finger examination. The cervix also has to be, if you still have a cervix, that needs to be mobile, or the end of the vaginal canal needs to be mobile. If if women have had hysterectomies, that vaginal canal can shorten. So we need to get that back. We need to get that length back. Because, by the way, all of this, and I know I've touched on a lot of different things, but it is all use it or lose it.

SPEAKER_02

So I was thinking that was going through my mind.

SPEAKER_00

Well, we you know, we talk about, and you said this, Cindy, like early intervention, but I think the bigger challenge is education because I do, you know, I work with a lot of women in paramenopause and menopause, I do a lot of, you know, systemic estrogen, vaginal estrogen, testosterone prescribing, but it is always a shock to the most kind of wellness focused and body-aware women that there is such a thing as an option for vaginal estriol. So when we talk about hot flashes and night sweats, right, I think to be honest, even in medical school, in naturopathic medical school, on women's focused, women's health-focused shifts in our clinics, I think we still forget about all of the other pieces of paramenopause and symptoms, you know, like, and we could list a million of them, but I think especially with the vaginal elasticity and vaginal atrophy, I think that gets missed out on. And so I don't think a lot of women are having those conversations with friends. They're certainly not with their primary cares or even their OBGYNs. And so it's almost a surprise to them when I ask, okay, let's talk about vaginal dryness. It's one of the things I hit, just like hot flashes and night sweats and dry mouth and itchy ears, and you know, the list of things goes on. Uh, but there's not even awareness that that there's something that can be done for that. And I think that is really fascinating in a horrible way. But I think it's not talked about enough.

unknown

Right.

SPEAKER_00

There are options for this, or that we should be thinking about this. So you might think it could go away, but you don't even know that there's something that can be done for it.

SPEAKER_04

Right. And there's there's there's also the gals out there that are too afraid to supplement with estrogen, especially if they run the risk of cancer, estrogen-driven cancers.

SPEAKER_03

So there are immediately endometriosis that sent you to the emergency room because you were given an estrogen patch.

SPEAKER_04

Yeah. And so immediately they there's this fear reaction to supplementing with estradiol, right? It's estradiol that we supplement with. Plus, there, I mean, there's the group of women that were part of the initial HRT's, everyone's on Premarin, right? And that that drug wasn't for everyone either. And so they threw it out. They threw out all the, but not only the premarin, they threw out all of it. So it's it's finding the right type of estradiol. It comes in lots of forms, right? So you could put a tablet in, you could put a little suppository in, you can put a cream in, but then it gets goopy. So they're like and so and again, it's goopy, I don't like it. I'm never gonna use it, right? So we have to meet people where they are and explain the differences in the various forms of estradiol, let them know that it's safe. Even for um, I'm a breast cancer survivor. I had ERPR positive, so estrogen and progesterone-driven breast cancer. So I asked my oncologist. And we know that estradiol suppositories are proven safe for breast cancer survivors. But that being said, you still have to be okay with it, right? I need to, I need to be able to sleep at night and I need to allow my clients to feel comfortable with it. But I can give them the data, right? They can talk to their oncologist and their gynecologist about a vaginal estradiol supplement. But people will also throw out their estrogen because they'll say, well, I've been using it twice a week and it doesn't do anything. Because maybe they need a different form, maybe they need to do it more frequently. The typical range once you get past the initial dose is twice a week. But I'm a huge fan of a vaginal moisturizer twice a week, too. And then even with the vaginal moisturizer, also a suppository, does come in liquid forms, and there are lots of products out there. But I do wish I would have invented the vaginal moisturizer, the suppository. Man, I you know, I talk about it every day. People come to me, like I buy my own and give out free samples because I think it's so important. So, so Estradiol twice. Favorite reverie. For sure. Right now, Reverie is my absolute favorite, and I really wish I would have invented it. I mean, it's changed my life as well as so many others. So it's a hyaluronic acid based. Well, they have hyaluronic acid in it. I'm not sure that that the hyaluronic acid is actually what's doing it. I don't, I think it might be the the fatty substrate, the actual moisture that it is encapsulated in. Intrarosa is a DHEA suppository. Very similar. Studies have proven that it really helps with dyspronia done twice a week. But unfortunately, I I'm not aware of this any studies that say it's safe for breast cancer. So my oncologist nicked it. I'm like, no, no, no. We'll just use the estradiol because we know that DHEA is a, for those of you that don't know, is the precursor to estrogen and testosterone. But because the studies aren't done yet with breast cancer patients, I don't personally use it. Um but again, is it the DHEA or is it the fatty substrate that it comes in? I don't know. The studies show that it works. It really does work for dysperonia. I personally can't use it though. I did use it prior to breast cancer, but since then, my oncologist, it's like hard now. So I'm a huge fan of Reverie. And then it's also timing. If my husband hears this, he's gonna be he doesn't really listen to the podcast. He's he's not a tech guy. But I'm a huge fan of putting that suppository in on Friday night and hoping I can get lucky on Saturday morning. Right? So I time my estrogen. So I take my estrodiol Sunday night and Wednesday night, and then I do my moisturizer on Tuesday and Friday night, and yay, Sunday or Saturday morning. Maybe I'll get lucky, and then I won't have to use as much lubricant, right? Because my tissue already has the moisture. It certainly really helps make sex feel better, much, much better. And the better it feels, then you know, I I always say bad sex begets worse sex, begets more painful sex, begets no sex, right? The worse it is, the worse it's gonna be for a whole lot of reasons, right? But that pain response, what's happening, someone's not listening, and I'm just pressing the buttons, I'm just going through the motions of it. But comfortable sex begets good sex, begets great sex, begets more sex, right? So you kind of have to make things as comfortable as you can in hopes that things feel better. Uh and it and again, it's not just about the moisturizer, then you need a good lube on top of it.

SPEAKER_02

I'm thinking about the chicken or the egg situation here because it's really easy. And I think typically when anybody says anything about libido, we're thinking about hormones. And as you're describing this, I'm thinking this could totally be a feedback situation, right? Absolutely. There are feedback loops involved. Yeah. Somebody's having the subtlest shift in comfort or pleasure that isn't necessarily enough to register as that's an issue, or it just wasn't that great. And maybe there's the next time it's not that great, and the next time it's not that great. And eventually now it's like, well, that's there's the decrease in desire because of that. And how could your protocol implement it at the right at the most appropriate time, which was probably way, I'm thinking about what Elisa was saying earlier, like the lack of education? It's probably way before most women would ever consider it, and because no one's talking about it.

unknown

Yeah.

SPEAKER_04

Yeah. For sure.

SPEAKER_02

What would be the ideal time in your mind to begin implementing a protocol like that, or even just some aspects of it?

SPEAKER_04

Well, so Oh, this is a tricky question. Because women have babies at all ages or or don't, you know. But sooner rather than later, I would certainly say by late 30s, we should be at least talking about it. I mean, some women go into menopause at 42. Right? Some women are screwed.

SPEAKER_03

So we're actually screwed, Cindy, because we're we're all screwed in 40s. Mid but still screwed. But you're gonna you're on the other, you're about to be on the other side. I'm not about it. Okay.

SPEAKER_04

So if we're teaching college kids about safe sex, aren't we behind the curve? Shouldn't we have taught them probably in in middle school with sex education?

SPEAKER_02

So that's such a big part of that was so there was so much taboo stuff, even with the the period and the shaming around that. And you know, obviously we're hoping that that is shifting. I'm certainly trying to do that with my son and helping him understand how important it is for women to go through this every month and how men can be supportive of that. But now enter this, I feel like our generation is doing so much of the healing around you know, the stigma of all the feminine, and here we are doing this now. So that's such an important I mean, better late than never. Yeah, oh for sure. For sure.

SPEAKER_04

Right? But but it should happen sooner rather than later, right? I mean, um You know, and I I've had women that haven't been in relationships, and so they come to me and they finally, you know, are super lucky and meet the person of their dreams at 47. And they're terrified because now what? Because it just it hasn't happened, or it hasn't happened in a really long time. So then we have to, you know, I I do a really thorough assessment. You know, is this a tissue thing? Is this a muscle thing? How do hormones and moisture and how does everything come into play? Mindset, you know, do you have the doom and gloom, self-fulfilling prophecy of, oh my God, it's gonna be horrible, it's gonna be horrible, or can we spin it to let's make this more comfortable, let's explore things. Let's, you know, I, you know, bring your partner in and let's talk about this. But it's a lot about exploration as our bodies change. What worked in our 20s is not necessarily gonna work in our 40s and 50s. Our bodies have changed. And um I think it's super important to have those conversations. And so when patients come in to see me, I try to keep it open-ended and ask a lot of questions, make sure people are comfortable and they know that, you know, in my four walls, that, you know, the information they tell me is going to stay there. Um, but we got to get comfortable talking about sex. I mean, I I also I talk a lot about just the physiological responses. I used to teach at San Agri State and St. Augustine and their physical therapy programs and discuss pelvic health and and pelvic PT for just a short course. And I have these great slides. And one of the the professors at St. Augustine gave me this slide. He's like, you gotta use this because this is exactly what you're talking about. And it's this old machine that has one button on it, and it's the male sexual response. You just press a button and things magically happen. Maybe it's press a button, take a pill, or take a pill, press a button, and everything magically happens. But with women on the female side of this very archaic computer, there were all these dials and levers and switches and and all these other things that need to happen. And and just like we have love languages, I think we have arousal and sexual response languages. So I also talk a lot about that because my and so. I also talk a lot about foreplay, right? You know, we need more for foreplay. We need to take more time. We need to be aroused. But my idea of foreplay is when the dishwasher is emptied, the garbage is taken out, and the dog has been walked without being asked.

SPEAKER_05

Yeah.

SPEAKER_04

And I need to hear, because I'm I am an auditory person. I need my husband to say, oh honey, you look beautiful today. You know, I that's what that's my foreplay. Like if it begins at like way early in the day, and then I need to work out, right? Because that's it's me. I I need to exercise. I mean, 75% of women say if they feel, if they exercise, they feel better about themselves. If we feel better about ourselves, then we might, we might, if the stars align, might be more interested in sex. But that that idea of foreplay is is way more than just foreplay. It's really like, how do we get aroused? Like men, and there's a great um, I just listened to a wonderful sex therapist. Um, and I came up with a quiz, kind of like that whole love language thing. You know, men, they can see something, you know, just visually, like, what are you wearing? How do you look today? They can hear something. Uh, and all of a sudden they're like, that's all I need. I'm ready. And for us, it it's just not like that, right? The moon and the stars literally need to align. I need to not be stressed. We have the dialogue, the list going on in our head of all the stuff we need to get done. And meanwhile, they're they're ready to go, right? So our our systems are different, but it's how do we communicate that to our partners? How do we and and and by the way, it is ridiculously easy for me to discuss this with my clients and their partners? It is much more difficult to discuss all of this with my own partner. These are these can be tough conversations to have. I mean, there are men out there that get very defensive with, you know, why are you telling me what to do? Don't you think I know how to just do this, you know, have sex? Don't you know why why do you have to be so directive, right? So there's that that whole thing too. So I always make my patients aware that they are sometimes difficult conversations to have.

SPEAKER_03

And you can also have women on the other side where they're they are uncomfortable having the conversation because of any number of reasons. And their their partner could be asking, please tell me what you want. And it and then that itself can almost even be a barrier to sex. Like that, that's like a turn off for some people, like having to talk about it too, right?

SPEAKER_04

Wait, if our if our physical would we go for a physical, whether it's you know, wherever you get your pap smear done, right? Does your doctor say, hey, how's your sex life? Do you want to talk about it? Yeah. You know, unless you're there, like you the client has to be the one to have those conversations, unfortunately, right? Because it is a there are a lot of factors. So I'm not saying all physicians, but but sometimes it's very difficult for them in all the things that they're looking at, you know, at a physical, or whether it's a well woman or just your annual physical, you know, you start talking about sex and it's like Pandora's box and no one really has time for it. And if the practitioners aren't comfortable about it, the patient's not going to be comfortable talking about it. There are a lot of cultural things, whether, you know, faith-based, past trauma. There, there's so many reasons to be uncomfortable talking about sex. So I try to try to get people talking. And then I have resources because I am not a sex therapist. I talk about sex a lot, but I am technically not a sex therapist. So when it comes to the relationship side of things, I do refer to some great sexual therapists out there. No, and God bless Zoom, because a lot of this stuff can be done remotely. But there's there are so, so many reasons to avoid it, not talk about it. So I think it's super important to get our clients discussing why or how or just their feelings, their experiences.

SPEAKER_00

I'm really interested also on your take, Cindy, with you know, how stress plays a role in that in terms of the pelvic floor. Because what I find a lot of times is, you know, I'll have patients who are doing all the right hormones, or they don't even need it, their hormones look great. I would say, like, you know, 90% of women come in and they're like, oh, it's the hormones, I just don't want to have sex. You know, we've got lubrication, we've got vaginal healthy vaginal tissue, we've got good testosterone levels. And so what I've come to realize is, you know, your hormones can be perfect, your tissue can be beautiful. And if there's something else going on, that stress is really a driver of that, sometimes lack of libido, but I'm also wondering how that manifests physically, if you have any kind of thoughts on that with our pelvic floor and the relationship with stress and sure that desire that's not coming from a hormonal place.

SPEAKER_04

Well, I mean, there are other drivers, right? That whole parasympathetic, sympathetic response cycle. You know, we're supposed to rest and digest and reproduce, or we're gonna fight, flight, freeze, right? And so some of us, when we're really stressed, we're kind of frozen, locked up, not breathing. So when we when we don't breathe well regularly, when we sit at the computer all day and we have to get it done, we have to get it done, we have to get it done. If we are not taking those deep breaths, our our our breathing diaphragm is directly related to our pelvic floor diaphragm. So when take our deep breath and inhale, we get this downward relaxation of our pelvic floor. When we exhale and blow all the air out, the diaphragm, breathing diaphragm comes up and our pelvic floor comes up. But if we're not breathing, we're usually stuck right there. So everything is kind of all up in a bunch. It could be tight, it could be, it may not give as well. If the muscles don't give, the vaginal canal is not going to give as well. And again, there's all the hormonal things. But stress plays a huge role in it in how we're feeling, how our muscles are feeling. You know, when our muscles are that tight, we can get trigger points. We can get, you know, there's diagnosis like vaginismus when the muscles are really, really just too tight. That is different from tissue tightness. Vaginismus is strictly muscular tightness, technically by diagnosis, but all these things kind of overlap. And again, can it be a protective response? But in addition to what's happening with the muscles, remember I said we got we have that dialogue running through our head. If we're stressed, are we really in the moment when we are attempting intimacy? So if we're really stressed and we're thinking about, okay, I gotta remember, okay, is what time's the game? I gotta bring snacks, I gotta get my work done. Am I gonna get there in time? You we have these dialogues running through our brain and and it takes us out of the moment, right? And then we're so stuck on that we're probably not breathing either. But if we're not in the moment, then we're not paying attention. We are not responding to our body's messages or allowing the response to happen. And again, it can become a vicious cycle. So it's super important to stay in the moment. I mean, there there is no Viagra for women, right? You can't take a pill. The drug that is out there is something called Addy, but it's in the psychological realm. And what does it do? It quiets our brain, it quiets the dialogue, doesn't change anything physiologically. Now, when men take Viagra or Cialis, those drugs are physiologically changing things. But Addy doesn't do that, it just quiets the dialogue.

SPEAKER_02

Because if it's a woman, that's gotta be something in her head, right?

SPEAKER_04

Wow, so people got really offended when Addy came out because it was in the site category. But but again, at least it was something, at least someone was trying. So what I do is I hello. I know, right? But it's out there for that group of women. But what I try to do is get people more in touch with their body, get their pelvic floor moving, get them breathing, get them exercising, get them more aware of what things look like in their vaginal tissue. I mean, there I have women that have come to me, they've never taken a look down there, ever, ever, ever. And then they say something's wrong. I'm like, well, how do you know? I mean, besides the itch, you know, besides the the things that are that they're superficially feeling, but they don't know what their vulgar tissue looks like. You know, I have mirrors and I explain things and uh and again, we ought to bring that body awareness. But there are there are exercises you can do. I do a lot of deep breathing with my clients, not just a relaxation breathing, but like, come on, let's rub it up and then breathing with motion, like let's get everything moving, um, to get them back into improving their sexual response, improving their muscle flexibility. Um, yeah, and trying to stay in the moment, right? If I do this crazy right-left breathing, then it can quiet the dialogue in our head. Does that make sense? I do crazy exercises.

SPEAKER_03

So when it comes to that, I can attest to some of the crazy exercises that Cindy will have people do. I've got like a bunch of questions for for all of you guys. Um I'm just gonna go down the list. So they're not necessarily gonna be all 100% connected, but it's stuff that we've talked about that I feel like I need clarification or I know somebody else needs clarification on. Aliza, you said estriol. Cindy, you said estradiol. We've got an episode where we talk about differences in hormones and and so we can put links to those episodes about hormone basics and some of the stuff about hormone replacement and whatnot for people to go back and listen to. I know that the conventionally and most commonly prescribed estrogen is estradiol. Aliza and Karen, I wanted to just check if you guys do the vaginal cream in estriol as well, since you that's what you had said, Eliza.

SPEAKER_00

Uh yeah, I do. I use estriol. Um, it's typically, you know, from a compounding pharmacy and not covered by insurance. So depending on finances, there are times when we can use estradiol as well. Um, that's from a, you know, a commercial pharmacy. Um, but I love estriol because we know that it's so amazingly supportive to the tissues, to the vaginal tissues. Um, and it's also, you know, less worrisome vaginally because it's being locally absorbed there, but also really protective against breast cancer. So I think for a lot of women that have had a personal history of breast cancer or have a really, you know, first degree relative with breast cancer, sometimes that, like you were saying, Cindy, like that can put their mind at ease too, knowing I'm using a form of estrogen that actually protects against breast cancer.

SPEAKER_04

Yeah. Yeah. So with estrogen, what what some of my clients have said is that, you know, I tell women, like, this is done at night, right? You brush your teeth, you floss your teeth, you put on all your lotions and potions, you do all the things we have to do, which is now like, I don't know about you ladies, takes me like 45 minutes to get ready for bed with all the things I have to do, right? There's a lot of upkeep on these human bodies, but they put it in at bed, right? You put it in right, you go to the bathroom last thing, you you put in your estriol, or yeah, and then you go to bed. What some women report back to me is that they don't like stickiness or or if they're using a plunger that it's gonna come out. But I am a huge fan of, especially when people are having financial issues with it, because like you said, Elisa, it's not necessarily covered by insurance. So I always tell them to talk to their doctor about it. But what if you get a prescription for the estriol, right? But you use the vagifem or the vaginal suppository twice a week, put the suppository way up inside the vagina so that it's working its way all the way down, but keep the estriol for the opening, right? That vulvar tissue. And again, we can get it right at the urethra, which also helps, right? Because it's gonna plump up that urethral tissue. It'll make their estriol last a little bit longer because they're not using as much of it. Then financially, it, you know. I just again, not everyone can afford this stuff. That it's kind of like reverie. Not everyone can afford reverie. So I'm constantly looking for the knockoff right now, right? So, and there are knockoffs. Yeah, but yeah, so I'm a huge fan. And then some people will still need some topical testosterone, right? Or a compounded S test on that vulvar tissue that can be super helpful.

SPEAKER_03

All right, so thanks for clarifying that for me. Before we I've got a couple of questions about sex itself, especially sex as you age. But since dryness is something that you've talked about a lot and has come up, comes up so frequently, and you just talked about, you know, the moisturizer.

SPEAKER_04

And again, I wish I would have invented it because I'd be I mean, my kids' college education would be well more funded if I had invented it, but I don't. But I love it. I love it.

SPEAKER_03

But so for for somebody, like let's say either they're in the place where they're like, oh crap, I hope that this isn't like gone. If it's like a use it or lose it, I hope it's not all the way lost. Like they've they've not been using things for a while, or they did just not having a lot of sex. So outside of sex, what would give somebody like an indication that they're they're they have vaginal dryness outside of sex? What does it feel like? Painful.

SPEAKER_04

Painful pelvic exams, or they go underneath their bathroom cabinet, and they go to the way back and they pull out that vibrator and dust it off. And they try to use it and they can't get it in.

SPEAKER_03

So it's really only with insertion that they're gonna know that there's dryness. It's not gonna be clear in daily life.

SPEAKER_04

No, for dryness, just looking at the vulvar tissue, it appears uh more red. We call that erythema, right? It it appears red, the tissue seems fragile. What's interesting is that a lot, it's it happens so gradually for so many of us that we don't realize it's dry until I say, you know what, just try the reverie. Here's here's a sample, like just try it. And they pop it in that night, and then the next morning they go to the bathroom and they go to wipe themselves, and they're like, oh my gosh, that feels so different. Like, I just didn't know it was that dry. But you don't know it until you added the moisture back in. But I will tell you, I mean, as a reminder, dryness always equates to pain. I I rarely use 100%, but I'm gonna say 100% of the time. Dryness is going to equate to pain. So repeated dryness, you you might see micro-tears in the tissue, but it's a good time to, you know, get out your magnified mirror, hold up your leg, and take a look down there. You know, you gotta look at your tissue. Because it is surprising to me when women come to me and I do take a look externally, and I say, Wow, you know, is this sensitive? We do something called the Q-tip test sometimes, where we use the tip of a q-tip just to touch the vulgar tissue, and it is red hot. I mean, angry red. And they're like, Yeah, I kind of feel something down there, but I I just kind of ignored it. And then I show them, and sometimes you can really see the tissue deteriorate, and that's where I want the estrial, right? I want the cream right on that tissue. Uh, because their doctor prescribed it, but they didn't know how to use it. They've just been shooting it up there, and half of it winds up on their undies the next day. So I go into the details of how you're supposed to use that cream. But yeah, those are are the general feelings. I mean, some women their their labia can rub, and that can be an irritating factor as well. So those are all signs of dryness. And then if they start in the loop of bacteria yeast, bacteria yeast, that's that's another sign that things are off.

SPEAKER_00

Well, the feeling of what I hear a lot from patients is the feeling that they might have a yeast infection. Like kind of like itchy, scratchy. So I actually had a friend who, I mean, I don't know for how many months was kept giving her self-sluconazole, and finally I was like, you don't have a recurrent yeast infection. I'm gonna give you some estriol. And she was like, Oh my god, everything changed. Oh yeah, right, right? Oh, it gets mist mistreated or miss self-diagnosed, I think, sometimes too.

SPEAKER_04

Yeah, and like why you feel bad, like why wasn't she just going to the doctor? Like, I I I always think it's and it's very important for vulvar vaginal health. If you suspect you have a bacterial or yeast infection, get the to the doctor and just get tested. Because you can't be guessing, because guessing and using fluconazole for antibiotics without an infection can really, really make things worse short-term and long term. So if anyone thinks they have an infection, they need to go it and and they need to get swabbed, right? They actually, you know, the nurse practitioner, doctor, PA need to do a swab, look under the microscope and say, Oh, yep, that's bacteria. Nope, that's yeast. And then it needs to be treated accordingly. But I'm not a fan of the guesswork when it comes to but good call on that, Aliza. That that, you know, really it was just dryness. It's that that itchy burny feeling. Yeah, that just discomfort. Yeah, yeah, yeah, yeah. Yeah.

SPEAKER_03

All right. So now my other questions, unless you guys want to talk about dryness more. My other questions are about sex. Um, and just a basically, you know, you said that um, you know, use it or lose it, do you have a recommended frequency that you tell people to aim for? Like going to the gym. How many reps do you need to do of this to maintain health?

SPEAKER_04

So it sounds like what you're saying, or or the question you're asking is what is a normal sex like? Right?

SPEAKER_03

No, I'm asking what do you recommend for people to maintain sexual health and pelvic floor, as it relates to pelvic floor and just sexual health in general? Like I know everybody's gonna have their different drives, but you know, there's it can be um, I would assume there's like a minimum that you really would like people to aim for.

SPEAKER_04

You know, but a lot of that depends on personal situations, relationships, that kind of thing. So if I, if tissue is tight, muscles are tight, and it's been a while, if I am prescribing the use of vaginal dilators, so these I mean they're they come in many forms. I want people to do that at least three to five days a week. For I say 10 to 15 minutes, knowing I might get half of that. Right? And you know, this is an old PT trick when it comes to like repetitions and length, like I'll tell people to do their exercises twice a day. And do you know what's gonna happen? They're gonna do it once a day. And if I say once a day, they're gonna do it three to five days a week. So if I tell someone to do something three to five days a week, guess what? They're gonna do it once, maybe twice. So like when I tell people, ideally, and I'm usually I can't play poker, so I usually just say everything that I'm saying to you right now. Like I really want people to stretch out their vaginal tissue, if that's the the problem area, at least three days a week, right? To improve their sex life. But I don't want people to get anxious or stressed about it because then that's gonna backfire. So when I prescribe vaginal dilators, usually I show them these are the options. I have samples in my office, and then I say you get a hundred thousand points, and nobody's keeping track, by the way, just for buying it. And then when you open up the box and stare at it, you get another 100,000 points. And again, no one's keeping score, but you know, personally, I I'm a big competitive person. Points are good. You know, sometimes you just have to stare at it. And then you can play around with it just with your hands, maybe touch it on your belly or your thighs or something. Like, yay, you get more points, and then put it away. And then when you're ready, maybe you can add the lubricant and just hold it at the opening, right? This can take a while before someone can fully insert a vaginal dilator. They come in different sizes, so you know I want things to be stretchy but pain-free because pain begets more pain, begets a lot more pain. So we need to break that cycle. We need to stretch the tissue, but not go into painful stretch. I'm also a huge fan of changing positions with these dilators, but anyway, that's if I'm prescribing dilators, you know, at least three to five days a week. It also depends on their motivation. So, new boyfriend, new relationship, you know, new partner. I want it, I, you know, I really, really do. They're super motivated. Ladies, they will they will sit with those dilators in half an hour, an hour a day, you know, if they're super motivated and they're gonna make progress faster. But, you know, someone that doesn't have that motivation or uh has more fearful past experiences, you know, it's we're gonna go a lot slower.

SPEAKER_03

Okay, but back to you've just talked about putting stuff in your vagina. I know.

SPEAKER_04

I was just getting there. But you know, if if you can have sex at least once a week, at least, maybe twice a week. But I will tell you, normal sex, you know, can be anywhere from every day, twice a day, which I know sounds like a lot, but I did have I do have clients that will come in, say twice a day, except Sundays, and I'm always like, whoo, that is impressive. Uh, I have people that have sex every day. I have people that haven't had sex in five years. Once a year on their anniversary is plenty. You know, it's I so I don't want to say what nor what normal frequency is, because it's different for everyone. But for healthy tissue, I think at least once a week, and there are no studies that I know that say this. So I'm, you know, this is clinical experience, personal experience, at least once a week. But I will tell you, if once a week turns into every other week, turns into once a month, it's another slippery slope. So you kind of have to make the time for sex. So if it's not happening spontaneously, so some people are super lucky and it does happen spontaneously. I need to.

SPEAKER_02

And this is this is for tissue playability, for like flexibility, yes. Yeah, your own connection to your pelvic bowl and you know, assessment of almost like maintenance, right? Like, is everybody working how it needs to be working? Is there any discomfort? Yeah, just if nothing else, a check-in, but also the the flexibility of the tissue, the flexibility of the tissue, right?

SPEAKER_04

Um, and just to throw it out there, guys think their penises are very hard. They're not that hard, they're very bendy, actually. They're softer than you think, even at full erection. But there's also, you know, what is our vulvo vaginal tissue like? If it's getting tighter, some people don't get tighter. Some people, I definitely get tighter. I like all my tissue. I have to work a lot on my flexibility. So it you kind of um you need to keep that tissue flexible. Yeah. Yeah, the penis is not as hard as you think it is. So practice. So, but I don't want to say take one for the team. You know, I want you to have that intimacy. So there are studies out there that so years ago, I think it was at UCLA, they did a study and they put um little electrodes on men and women uh to assess what their brain activity was like during sex. And um, I don't know how much they paid these participants, but I hope it was a lot. Because they put the EEG, I think it was, so all the little electrodes on and said, go have sex. So they did. And no surprise, when men achieved orgasm, every happy center in the brain went off. Like electrodes just fired everywhere. So men think that the orgasm is super important, right? Because that that just is it's a positive feedback loop and they want more, and it all the happy centers went off and they feel great. When women had sex, I remember this was sex, I'm not sure these were relationships, but if they achieved orgasm, it was like a poof, yay. But what the happy centers all went off when we had that intimate connection. It was about the journey, it was about all the coddling and and all that other feel-good stuff. This again goes back to those languages, right? But men think that we all need an orgasm, but many of us don't.

SPEAKER_03

And orgasms definitely talk about orgasms because that's my last question. You know, like so maybe we maybe we don't all need them, and maybe we do. And maybe that that can be a big part of the shift in drive and you know, TMI perhaps, but like that's part of my shift in drive, is because since I shifted into Perimenopause place, it is like it my the ability to achieve has like diminished, or when like when it does come, instead of being a kapow, it is a and it's like yeah, and it's like, oh my gosh, that was so much work and so much effort, and I had to do so much extra things, and apparently I need to moisturize and um, you know, all these things that we need to do to make it even possible to then go poof, and it's like, but if I'm getting my feed, my feedback loop from like you did the dishes and then you walked the dogs, then like anyway, is there any hope that through the work that we do with frequency and tending to our pelvic bowl and all of the sta the things that we can do? Is there any hope of it improving that? Or is that something that we just have to shift and our expectation with as we are aging?

SPEAKER_04

There is definitely hope in improving it. Definitely hope. Absolutely. I think it's getting the right information. I think it's that intimacy is really important for a lot of women. So there's that, but there's that component. I think it's how we feel. You know, pain is also stressful. So we want to be out of pain. Uh pain anywhere, right? My back, my hip, my oh my god, my calf just cramped, you know, just all those funny things that happen. There's just so many factors, but the orgasm can be elusive. I do want to say, I truly believe, this is my belief, any orgasm is a good orgasm. Internal, external, I don't care how you got it, just keep having them. But there are things we can do to optimize the possibility of an orgasm. Um, and again, everyone's different. This this goes back to I I have people now take a little quiz. Let's get the information where where are your arousal areas? You know, let's let's work on those and let's communicate the importance of those to your partner. But let's make sure that you don't have a list of to-dos running through your head when you're having sex. Let's make sure that tissue is optimal, that you're moisturized and you have the right lubricant and and you feel good about yourself and that you're not in pain. There's just so many factors. But there are exercises I do with patients to get them revved up. And again, a lot of times it goes back to breathing and movement in various positions. And positions can make a huge the position that worked when we were 20, I can't achieve those positions anymore. You know, my hips don't bend that way. You know, you got to try something else. And it's super important to communicate with your partner because they probably don't work as well either. They think they do, but they don't.

SPEAKER_02

I definitely, I definitely understand what you're saying about women not necessarily needing orgasm for connection with their partner, right? Like a sense of intimacy with their partner. Psychologically, I know that there is tremendous benefit in neurochemical health with orgasm, just for the individual, not necessarily in a in a relationship. And I and I'm really curious about the vaginal health and the pelvic bowl health related to orgasm. You know, we're we're talking about one once a week having that introduction of or more something for for flexibility. But what about what about the orgasm for, you know, maintain the workout, as Jen was saying earlier. Right.

SPEAKER_04

So it is a workout, right? So when you do achieve orgasm, it's a very different contraction, right? And the our glandular secretions also improve, right? There's just more secretions. Um, but that contraction is a is different than just doing a pelvic floor contraction or a kegel, right? You're in a different position, it's more intense. Uh, there's a a voluntary and involuntary component to it. Um, and I do think it's important. Um, I and I do try to help women uh achieve orgasm more easily, whether that's with a vibrator, whether that's with self-stimulation, whether that's with, I don't know, what whatever. You know, a shower hat, uh whatever it is. I I want women to be able to have that response, but I don't want them to get hung up on what happens if I don't have it. Because no one's broken if they don't have it. That's why I'm kind of I'm walking that line. I I want to make sure people know that sometimes you're just not gonna have it. I mean, and that's okay because physiologically it didn't work out. The timing was off. I was thinking about the groceries, I was not in the moment, and I don't know, I just don't feel good about myself today. You know, there's that type of stuff, and I I want women to be okay with it, but you know, having an orgasm usually begets having more orgasms.

SPEAKER_03

So don't give up, basically. Like even if you have a rough day or a rough streak, it's worth continuing to try because it's not just gone.

SPEAKER_04

It's not just gone. Yeah. I mean, I I do have clients that will come in and they have an orgasmia, meaning they've never had an orgasm. I try my darnest to help. But are they wired differently? Do medications play a role? Antidepressants, you know, constipation. So pain meds again. We're back to those pain meds, you know, back to bowel regularity. Isn't that weird how I can like loop it all around again? So it makes a difference though. All of those things make a difference.

SPEAKER_02

So I really appreciate how you're helping to expand our understanding of vaginal health and fitness, vaginal fitness and vaginal health. I I really I really I talk a lot about sex in in my work, and I just really appreciate the the expansion of, you know, flexibility and you know, spending time once a week doing this kind of work, which doesn't necessarily have to be specific exercises. It can just be, you know, I I tend to my mental health, I tend to my dietary health, I tend to my relationship health, I tend to my vaginal health. I just really love how this conversation is incorporating that and integrating all of that for us.

SPEAKER_04

Yep. And there's so much to do.

SPEAKER_03

I'm looking at the time and uh the attention span that we have for people, and I'm wondering if we should pause and stop for today. I know we have a few listener questions that are probably on many people's minds. That Cindy, if you're willing to do one more quick episode with us to answer a couple of listener-submitted questions, that would be really wonderful just to help people know where to start with things. So does that sound good to everybody? Absolutely. Any final thoughts on sexual health before we wrap for today?

SPEAKER_04

Go get them, ladies.

SPEAKER_03

Perfect.

SPEAKER_04

Any way you can. You get that orgasm.

SPEAKER_03

My last little thought, because you shared with us in the episode about the party trick that you had when we were talking about bowel health and that you can get people to do the like poop massage, right? I wonder if you also have a party trick where if you can look at people and like how tight they are in their bodies, we can be like, all right, I know how tight your vagina is probably right now.

SPEAKER_04

Well, I wish I had that ability, but no, but I can't. I can usually wrap them up though. I mean, with some exercises, but but no, I don't have that. What what we see on the outside is not necessarily what's on the inside.

SPEAKER_03

Well, because you'd said that you like that you shared you're tight everywhere and you need to stretch. So I didn't know if that was a general thing. Like if you are tight in other parts of your body, if there is reason to expect that maybe you're tight in your vagina too.

SPEAKER_04

Oh, well, yes, there's there's that. But some women, it to it depends on a lot of other factors like birthing history and you know, vaginal delivery, C-Sa. Yeah, there's all kinds of things.

SPEAKER_03

So I guess it's not a cool party trick that you're gonna do. You're just gonna have to help make people poop. It's I mean, that's a magic trick anyway, enough of in a future episode.

SPEAKER_04

Maybe we can all rev ourselves up together and I I can show you some heavy breathing and and see how that works out for you.

SPEAKER_03

All right, maybe in our next episode where we answer our listener questions and you can give us a few things that we could all start doing on our own when we need to. So that would be fantastic. All right. All right. Until then, take care everybody. Thanks for having me. Bye.

SPEAKER_02

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SPEAKER_01

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