In this blog, Elaine Miller, a physiotherapist who also does a stand-up comedy show about pelvic floors, tackles sex and the menopause.
Page last reviewed: 02 August 2022 and updated with an editor’s note on 30 August 2023.
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 a 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 well-being 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 A measure of a screening or diagnostic test’s ability to correctly detect people who have the disease. 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 its own right. [Editors’ note: Physiotherapist Myra Robson has written a blog here – Pessaries for pelvic organ prolapse – looking at the Cochrane evidence, in which she also discusses pelvic floor exercises.]
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.
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 healthcare professional is vital, though broaching sexual function issues can be difficult.
It is important that awareness of sexual problems are included in health professionals’ Continuing Professional Development programmes, which include exploring and challenging assumptions and beliefs about sexual behaviours, and providing 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.
Resources on menopause
The Editors have added these in April 2022. With thanks to @drhannahshort, GP Specialist in Menopause & Premenstrual Disorders, for her suggestions.
- You can find our other blogs on menopause here.
- Balance: Founded by Dr Louise Newson, “a GP and Menopause Specialist who works to increase awareness and knowledge of the perimenopause and menopause, and campaigns for better menopause care for all women”.
- British Menopause Society: tools for clinicians and Menopause Care Resources Toolkit
- Daisy Network, a charity providing information and support to women with Premature Ovarian Insufficiency, also known as Premature Menopause.
- European Society of Human Reproduction and Embryology – Guideline on the management of premature ovarian insufficiency.
- Global Menopause Inclusion Collective
- Healthtalk – Menopause. Here you can see videos of women in the UK talking about their menopause experiences.
- International A relationship between two characteristics, such that as one changes, the other changes in a predictable way. For example, statistics demonstrate that there is an association between smoking and lung cancer. In a positive association, one quantity increases as the other one increases (as with smoking and lung cancer). In a negative association, an increase in one quantity corresponds to a decrease in the other. Association does not necessarily mean that one thing causes the other. for Premenstrual Disorders: Surgery and surgical menopause for premenstrual disorders.
- Rock My Menopause (created on behalf of the Primary Care Women’s Health Forum)
- NICE guideline – Menopause: diagnosis and management.
- NHS – Menopause
- Women’s Health Concern factsheets
Editor’s note, August 2023: The Cochrane Review Hormone therapy for sexual function in perimenopausal and postmenopausal women was updated this month. The authors found that:
• “For women within 5 years of their last period, Something done with the aim of improving health or relieving suffering. For example, medicines, surgery, psychological and physical therapies, diet and exercise changes. with estrogen alone probably slightly improves sexual function based on the sexual function composite score compared to An intervention that appears to be the same as that which is being assessed but does not have the active component. For example, a placebo could be a tablet made of sugar, compared with a tablet containing a medicine..
• For women whose last period was more than 5 years earlier, estrogen alone probably makes little or no difference to sexual function based on sexual function scores compared to a placebo.
• For both groups of women, we are unsure of the effect of estrogen plus progestogens, synthetic steroids, selective estrogen receptor modulators alone, or selective estrogen receptor modulators plus estrogen on sexual function compared to placebo or no treatment.”
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.