In today’s guest blog, Elaine Miller, a physiotherapist who also does a stand-up comedy show about pelvic floors, tackles sex and the menopause.
I have a faded post-it note on my office wall that says “what most people need is a really good listening to”. It’s sound advice for life, but, particularly useful whenever a patient brings up a sexual function issue in clinic.
Menopausal women often experience changes in how they think about their bodies and sexuality. Many have sad feelings about the loss of fertility and the body of their youth. Of course, some women relish not fearing unwanted pregnancy and finally feeling comfortable in their own skin.
Sexuality is not just about having sex, and sex is about more than penetration. A lack of intimacy, in whatever form, negatively impacts our wellbeing and so it’s important that people have opportunities to seek information or help for these issues. Often there is a Catch 22 where health professionals are hesitant to discuss sexual health with older patients, whilst the person is reluctant to broach these topics for fear of embarrassing their caregiver.
People usually learn about sex in a haphazard way and, if they have a long-term partner, will, hopefully, settle into a satisfying conjugal habit. Menopause can disrupt those habits and make it difficult to enjoy sex – which can have a profound impact on a person’s quality of life and relationship. The misconception that sex is the domain of the young can be a barrier for older people seeking help in managing troubling symptoms, and the near total absence of any reference to later-life sexuality in the media means there is little for people to compare their own experiences and expectations with.
Let’s have a look at the way that menopausal symptoms interfere with having a satisfying sex life.
Ovaries and adrenal glands produce small amounts of testosterone which may be linked to libido in women, though this role is unclear. Of course, some women find losing the fear of unwanted pregnancy is liberating and that can have a positive effect on her sex drive.
The effect of menopausal uro-genital changes on sexual function are well known:
Vaginal dryness and a changing sexual response are linked to the loss of oestrogen. The vaginal tissue thins, becomes less elastic and more prone to injury. A reduction in the blood supply to the tissues of the vagina affects lubrication and so penetration can be uncomfortable at best, impossible at worst. It can also affect sensitivity to touch, which can make it more difficult to become aroused. Vaginal atrophy affects about half of postmenopausal women, but only about 20% report symptoms. It presents as:
- vaginal dryness
- painful penetration
- spotting of blood after intercourse
- vulval itch
- vulval swelling
Good hygiene is important – wipe from front to back, use water to wash and avoid perfumes, douches and scrubbing. Menopausal bits should not be treated as if you are trying to scrub grass stains out, not even if your genitals happen to be covered in grass stains.
Lubrication is a friend to the peri- and post-menopausal – it doesn’t have to be sticky or medical looking and can be bought online or over the counter. Most can also be used for massage, which makes it easier to get a dollop where you need it to be. “Yes!” is now available on prescription in water or oil form. Oil based lubes are longer lasting, but, be careful as they are not condom friendly and sexually transmitted infections (STIs) are dramatically on the increase in the over 50s.
Coconut oil is a good alternative for those who prefer a natural lubricant, or who have run out and don’t have time to nip to the chemist but do have just enough to sprint to the kitchen cupboard.
Urinary frequency (more than eight times a day or more than once at night), urinary incontinence or recurrent urinary tract infections are associated with urethral thinning, vaginal atrophy and pH changes. Oestrogen loss also has an effect on collagen strength which can affect the pelvic floor muscles.
Fifty percent of women over fifty years old have some degree of vaginal prolapse, the symptoms of which (pelvic pain, pain on penetration, urinary and bowel symptoms) can also interfere with a sexual relationship. Pelvic floor exercises can be an effective tool in managing the symptoms of prolapse, but that’s a blog post in it’s own right.
Hormone Replacement Therapy (HRT or HT)
HRT can help the symptoms of menopause and can be taken either orally, applied to the skin or inserted directly as a pessary, and will be prescribed by your GP. There are benefits and risks associated with HRT, which need to be weighed up, and a wide variety of different methods of application. So far this week we’ve had two blogs featuring Cochrane evidence about HRT. Now here’s some more:
The role of testosterone
Of course, whilst dryness and discomfort can be sorted out with HRT, pessaries, lubrication and persistence, you may find that your libido is still lagging behind.
There are studies that show that adding androgens to HRT can have a positive effect on sexual functioning in post-menopausal women (see the links below), but all studies report difficulties in measuring female sexual response as arousal measured in a laboratory does not always correlate with what women report.
Sexual health is complicated!
The word most commonly found in the literature describing women’s sexual function and health is “complex”.
Sometimes, a sexual “dysfunction” is a reasonable, rational response to relationship complexities, changing self image and medical worries, as well as cultural and faith standards. Add to that the obstacles of stress and lack of privacy from boomerang kids, caring for ageing parents or young grandchildren – and, perhaps we should be wondering how menopausal women manage to have any sex at all?
Measuring female sexual function is difficult – the literature is full of papers debating how to define it. An orgasm does not necessarily mean the woman found her sexual encounter to be satisfying any more than a lack of one means it was not.
Cuddling and hot flushes do not make good bed partners. Sweat is rarely sexy, not even if it is Brad Pitt having a night sweat all over your Egyptian cotton sheets. Sleep disturbance means there’s less energy for sex. Medication for other medical issues may affect libido (there are many, particularly anti-depressants and high blood pressure medication; a change of prescription might help), as can worry about other medical issues.
Taking regular exercise, having a good diet, managing stress and making time for each other is important. As is investing in separate duvets.
The importance of communication
Communicating with your GP or HCP is vital, though broaching sexual function issues can be difficult. (Contrary to popular belief, no one likes talking about sex in Holland either, as this study of sexual health care needs found.) The Sexual Advice Association has some very good factsheets about how to ask for help with sexual matters, and for professionals about how to take a sexual history, here.
It is important that awareness of sexual problems are included in professionals’ Continuing Professional Development programmes, which include exploring and challenging assumptions and beliefs about sexual behaviours, and provide information about where to refer people to if they need help that falls out with practitioners’ scope of practice.
Communicating with partners is vital. The best indicator for having a satisfying sex life post-menopause is having a satisfying sex life pre-menopause and communication goes a long way in managing the changes that this life stage will bring to your relationship.
If you feel embarrassed about talking about problems with your sexual function with your GP or partner then try writing down bullet points. I’d recommend using a post-it-note with the first one saying that what you really need is a good listening to.
You can follow Elaine on Twitter @GussieGrips, where you can not only join in the conversation but also get her regular reminders to do your pelvic floor exercises! You might also like to read her blog for Evidently Cochrane on pelvic floor exercises and incontinence here.
Formoso G, Perrone E, Maltoni S, Balduzzi S, D’Amico R, Bassi C, Basevi V, Marata AM, Magrini N, Maestri E. Short and long term effects of tibolone in postmenopausal women. Cochrane Database of Systematic Reviews 2012, Issue 2. Art. No.: CD008536. DOI: 10.1002/14651858.CD008536.pub2
Cody JD, Jacobs ML, Richardson K, Moehrer B, Hextall A. Oestrogen therapy for urinary incontinence in post-menopausal women. Cochrane Database of Systematic Reviews 2012, Issue 10. Art. No.: CD001405. DOI: 10.1002/14651858.CD001405.pub3.
Bolour S, Braunstein G. Testosterone therapy in women: a review. International Journal of Impotence Research 2005;17(5):399-408. Available from: http://www.nature.com/ijir/journal/v17/n5/pdf/3901334a.pdf
Davison SL, Davis SR. Androgenic hormones and aging – the link with female sexual function. Hormones and Behavior 2011;59(5):745-53.
Traa MJ, De Vries J, Roukema JA, Rutten HJ, Den Oudsten BL. The sexual health care needs after colorectal cancer: the view of patients, partners, and health care professionals. Support Care Cancer 2014;22(3):763-72. Available from:http://link.springer.com/content/pdf/10.1007%2Fs00520-013-2032-z.pdf