“That part of my life is over” said my lovely 68 year old patient as she sat at my consultation desk across from me at our first meeting. I had asked if she and her husband were sexually active, as part of our initial intake. When she answered she didn’t exactly seem unhappy — more like resigned — like that it was just a “given” that the answer to the question was “no”. Of course my automatic follow-up question was “Is that ok with both of you?” (Lesson #1 of evaluating sexual disorders= it’s only a problem if the patient thinks it’s a problem). Her answer was sad — “No it’s not ok! I love my husband and I want to, and I know he wants to. But we can’t. So we don’t. And then we don’t talk about it and we just live this way.” She suddenly seemed teary eyed at the prospect of actually letting it all out.
This is actually not an uncommon scenario — and not necessarily restricted to the over-65 age group. Truth is many couples for many different reasons lose that part of their relationship gradually and never address it. If it causes distress then it is something that should definitely be discussed in the doctor’s office — even if the doctor or health care provider doesn’t initiate the conversation.
With this particular patient (as with all others) it was important to get a history on the problem — what was the relationship like before? Physically? Emotionally? What prompted the decrease in sexual interest and activity? Was it a physical problem? A relationship issue? Was there pain? Illness? Just lack of interest? To use an old adage — which is more true in intimate and physical relationships than almost anywhere else — “if you don’t use it you lose it!” — meaning once the habit of NOT having sex becomes an established pattern, as time goes on, both physically and emotionally, it becomes more and more difficult to return to having that sexual relationship again.
In this case, as time went by, the patient noted that intercourse was beginning to get uncomfortable. They initially tried various positions and lubricants, and even used coconut oil, on someone’s recommendation but it did not seem to relieve the discomfort. She found that her bladder would get irritable after sex, and remain so for days, and sometimes she would just feel sore. This went on for awhile and she was reluctant and embarrassed to talk to anyone about it, so she just started avoiding sex. Then her husband started having some issues with erectile dysfunction (as most men over a certain age may deal with from time to time) so their timing was off as he tried to “complete the act” before losing his erection — and with her pain and lack of lubrication they just both started avoiding the act — and the subject — for long periods of time. Before they knew it, months and then years had passed — and while she was sad about it she was still too embarrassed to seek help. The relationship seemed fine in other areas; but something was missing.
My role in this is to talk, to examine, possibly to diagnose, and to try to come up with a plan that would work for them, to return them to the intimate part of their relationship. This takes time, and evaluation, information, thought, education, and desire, for all involved.
I did a full exam. I was not surprised to find that the entire genital area was dry and tender — even slightly touching some of the area gently with a cotton swab seemed to cause extreme discomfort. I noted that even before I touched the area however, her muscles were tense and she seemed to be bracing for pain. With a slow and gentle exam I was able to tell that although the tissue seemed dry and irritated, a large part of her perception of pain was coming from the fear and anticipation that there actually would be pain rather than actual soreness or tenderness at the time of the touch. I explained to her that this is a common cycle — when someone anticipates pain, they involuntarily brace for pain. Their muscles tighten up — the fear of the touch and the resistance to penetration takes over, leading to more discomfort — more anxiety — more involuntary muscle spasm — and the cycle continues. It is important to try to determine if there is actually a number of physical/medical conditions, as well as what the possible psychological/emotional contributions are, to decide the best approach to treatment.
After doing a thorough exam, especially to be sure there was truly no physical reason that she would not be able to eventually return to the physical and intimate relationship that she desired — I offered her a program that would be designed to help her get there.
It took about 8 weeks of office visits- and a program that included use of medications, hormonal creams and suppositories, local anesthetic medications, relaxation exercises, dilators in a program designed to gradually change the diameter of the vagina, consultation with a sex therapist to address any emotional issues that the patient and her husband had preventing them from moving forward; and use of a vaginal laser to help maintain all the healthy changes that had been achieved. (Not every program includes every one of these options).
In the end, the patient felt ready to apply all that we had worked on for those weeks. She told me of her plans for a very special evening with her husband. She returned to the office several weeks later and reported that, while things were not completely perfect, they had had a lovely, intimate and successful evening. We discussed how to keep things from ever moving backward again and how to maintain the success she had achieved. She told me she was glad she told me about the problem, and thankful that I had brought it up. It made me feel so happy for her.
And every year, on their anniversary, they send me flowers.