A loose pelvic floor may be interfering with your fun in the bedroom.
You're probably on intimate terms with every sag or bag on your face. But it's actually the aging you can't see -- in the muscles and ligaments of your pelvis -- that may be crimping your sex life. "As the years go by, the muscle tone of the pelvic floor changes, becoming more lax, which can make orgasms more difficult to achieve and decrease the intensity when they do occur," says Jennifer Berman, MD, director of the Berman Women's Wellness Center, in Los Angeles, and coauthor of For Women Only: A Revolutionary Guide to Reclaiming Your Sex Life.
In addition, the pelvic floor -- the tissues that hold your uterus, bladder, urethra, vagina, and rectum in place -- can become so loose that an organ (most often the uterus) shifts out of position and protrudes into the vagina, a condition known as pelvic prolapse. That can produce the uncomfortable sensation that your organs are falling out of your body, which is true only in the most extreme cases. But any level of prolapse can dampen sexual pleasure by making intercourse painful.
Nearly half of women ages 50 to 79 experience some degree of prolapse. "If you've lived long enough, are physically active, or have had babies, you're probably going to have the condition," says Lauri J. Romanzi, MD, associate professor of gynecology at the Weill Cornell Medical Center in New York City and author of Plumbing and Renovation, a new primer on prolapse surgery. The strongest candidates are women who have super-elastic connective tissue, went through a prolonged second (pushing) stage of labor, gave birth to big babies, or a combination of the three.
The good news: In the last decade, there's been significant progress in finding ways to polish up that floor.
Dental Floss for Your Pelvis
That's what Romanzi calls the pelvic muscle-tightening exercises known as Kegels -- and for most women, performing them regularly is just about as exciting as practicing good dental hygiene. Yet studies have found that a "Kegelizing" program enhances orgasm. (And no less an authority on the boudoir than the president of France, Nicolas Sarkozy, is reported to be receiving personalized pelvic floor training, presumably to increase his sexual pleasure.) The exercises also help ameliorate incontinence and keep prolapse from progressing by strengthening the necessary muscles.
But forget the complex pelvic floor routines that used to be recommended (300 squeezes a day?!). The latest thinking is that you can do the job with minimal reps -- eight to 12 controlled contractions, twice daily. Romanzi suggests working both the fast-twitch and slow-twitch muscle fibers: For one set, hold your contractions for five to 10 seconds; for the next set, contract for a second, then relax for a second, repeating eight to 12 times.
It's surprisingly easy to contract the wrong muscles, so check your form. Lie down with your knees in the air, then hold a mirror to your perineum -- the skin between your vagina and anus. Do your best Kegel, contracting your muscles as if you were staunching the flow of urine. "Your perineum should retract a little, as if it is being drawn slightly into your body," Romanzi says. Your butt should stay relaxed and your hips should not tilt. If you're not sure you're doing the contraction right, ask your gynecologist. You can also consult a physical therapist who specializes in pelvic floor issues. (To find one, see "The Physical Therapy Solution," next page.) These therapists can gauge pelvic floor strength and train you to exercise the proper muscles, often using internally worn biofeedback devices.
A Support System
The simplest fix for pelvic prolapse is a pessary -- a diaphragm-like device that acts like an orthotic for the vagina. Don't be put off by its name. "The only thing wrong with pessaries is the word pessary," quips Romanzi. "It's associated with the notion of little old ladies falling apart."
Like a brace on a weak knee, pessaries restore organs to their original positions, which remedies the prolapse. A doctor can fit you for one of 60 to 70 different models, most of them designed to be removed daily or weekly for sex or cleaning. Women who use pessaries are often also prescribed an estrogen cream or tablet, which helps strengthen vaginal tissues and prevents the device from rubbing them sore. As a bonus, the estrogen combats vaginal dryness.
If your prolapse is mild, you can use a pessary only during exercise or other activities that are bothersome. The device can allow you to delay surgery, if the timing isn't ideal, or avoid it altogether. "I've had patients who insisted on having surgery," says Romanzi. "I drag them to the table to fit them for a pessary, just to hold things at bay until we can get into the operating room, and then I never see them again. They show up three years later, asking, 'Do you think I need a new one?'"
The latest pessary, called the Colpexin Sphere, does double duty: It improves mild to moderate prolapse while also giving your pelvic muscles a workout.
Going Under the Knife
About 11 percent of women with prolapse eventually undergo corrective surgery. Several studies have shown that this kind of repair significantly boosts sexual functioning, and a recent University of Pittsburgh Medical Center report concluded that the surgery enhances body image and mood, which can only help in the bedroom.
But think twice if your doctor suggests removing your uterus in the process, an unfortunate but long-standing medical tradition -- prolapse accounts for about 13 percent of the hysterectomies performed in the U.S. each year. "Taking the uterus out to fix a prolapse is like taking off the kneecap to fix a torn ligament," says Romanzi. And it's murder on your sex drive: Hysterectomy reduces blood flow to the vagina and ovaries, which can lower levels of sex hormones, limiting arousal and pleasure. If you're facing surgery, ask about uterus-preserving prolapse techniques like uterine resuspension or hysteropexy. Also consider newer, minimally invasive laparoscopic techniques performed through the vagina. They typically cause less pain, and involve no scarring and a shorter recovery than more invasive techniques.
-- Ginny Graves
Originally published in MORE magazine, May 2009.