As women age, they are two to three times more likely than men to be affected by a decrease in sexual desire. We'll spend the next few weeks talking about sex and menopause, including describing some of the common issues experienced by menopausal women and ways to get your sex life back on track. Please let me know in the comments if there is anything in particular that you'd like to know.
The mechanism of libido decrease in women during menopause is not fully understood but likely is a combination of decreased estrogen production (which causes vaginal dryness and painful sex), concerns with body image as menopausal weight gain changes body shape, depression and anxiety from dealing with hot flashes, brain fog, and lack of sleep, as well as numerous other factors.
During the menopause transition, the physical effects of falling estrogen levels—including hot flashes, night sweats, and vaginal dryness—can undermine desire and arousal. Studies have shown that a fulfilling sexual relationship improves the value of a relationship, and a bad sexual relationship can drain the lifeblood from a relationship. Women reporting lower levels of sexual interest and desire have lower body image, less self confidence, decreased self worth, and are worried more about their partner cheating.
Let's talk about anatomy first to make sure we are all using the same words. The vagina is the internal canal. The vulva is the part on the outside. There are two parts of the vulva - labia majora which is outermost and usually is covered with hair - and the labia minora which lacks hair and is inside the labia majora. The clitoral hood protects the clitoris and retracts when you are sexually excited. It's important for you to know where your clitoris is located and communicate that information to your partner since, for most women, clitoral stimulation is required for orgasm. The urethra is located below the clitoral hood and is where urine comes out. Your vaginal opening is where babies come out. All women have these parts but how they look differs significantly. Be assured that however yours looks, it's normal. Avoid comparing yourself to images on the internet or in porn. Nothing good will come from it.
Let's also make sure we're talking about the same thing when we talk about sex. In this context, sex is any experience with your partner that increases intimacy and brings sexual pleasure. Sex includes intercourse (penile-vaginal), but also oral and anal play, manual stimulation of the genitals, cybersex in which partners trade suggestive messages, photos, or videos while masturbating, and any other activity that results in consensual sexual pleasure.
The sexual response cycle is composed of four phases: desire (libido), arousal (excitement), orgasm, resolution. Different people spend more or less time in each phase and the intensity of the phases differ. For many women, the order of the phases are shuffled. (Men have a much more straightforward and predictable cycle.) For everyone, the sexual response cycle can change over a lifetime and even day-to-day. All of these responses are normal.
Treatments for sexual issues depend on the cause(s) but often involve a combination of medications, counseling, and self-care. You should talk to your doctor about whether medical interventions are appropriate. Some options your doctor might consider include:
Low libido - Consider switching medications (certain antidepressants or blood pressure medications) that are known to decrease libido. You also might try DHEA or testosterone - they are not FDA approved for low libido but some women report improvements.
Arousal/orgasm difficulties - It appears that some drugs (like PDE-5 inhibitors) can increase blood flow to your clitoris, but there is not enough data to know whether this blood flow increase results in improved sexual function. I've prescribed a compounded medication called Aarhousal Cream that is an ointment with a combination of medications that also may increase clitoral engorgement and sensitivity. The medications are not FDA-approved for female arousal, but some women benefit from their use.
Vaginal dryness/atrophy/pain during sex (genitourinary syndrome of menopause is the medical term)- Choice of therapy depends on the severity of symptoms, the effectiveness and safety of treatments for the individual patient, and patient preference. Vaginal moisturizers are available without a prescription and provide relief for many women with mild symptoms - I've had good success with this one, which does contain a low dose of estriol. Skip moisturizers with added botanicals, fragrances and flavors, sulfates, phthalates, formaldehyde, glycerin, chlorhexidine, parabens, benzyl alcohol, propylene glycol, or lanolins, since they can be irritating - a good rule of thumb is the fewer ingredients, the better. A recent review of vaginal moisturizers containing hyaluronic acid, which is as effective as low dose vaginal estrogen according to recent studies, can be found here. Vaginal dilators are a simple, drug-free method to promote vaginal health and blood flow. The dilators only need to be used 5-10 minutes per day and should be used with lots of lubricant: I often recommend multi-purpose Albolene Moisturing Cream, a mineral oil-based product that has no fragrance or harsh chemicals and leaves no soap-and-water residue or dryness. Prescription vaginal estrogen can help with moderate to severe symptoms and comes in a variety of doses and preparations including pills, patches, inserts, creams, and other preparations. Vaginal DHEA also demonstrates efficacy at reducing pain and dryness. Women experiencing additional symptoms, like hot flashes and night sweats, may be candidates for systemic estrogen therapy. Some women may be candidates for the drug ospemifene (Osphena), which is a selective estrogen receptor modulator (SERM) used for treatment of moderate to severe vaginal dryness and/or painful intercourse due to menopause. Osphena is a non-hormonal therapy that may be appropriate for women for whom estrogen is not recommended, but it is cost-prohibitive ($292.90/month according to GoodRX) for many patients. Finally, women of all ages, but especially older women who have had children, benefit significantly from pelvic floor physical therapy. Talk with your doctor about which treatment options will work best for you.
Just a quick word about a treatment called fractional laser therapy (MonaLisa Touch). I have patients for whom the therapy was life-changing and worked better than any other treatments. The North American Menopause Society (NAMS) notes, however, that there are insufficient placebo-controlled trials of vaginal laser therapy to draw definitive conclusions about efficacy or to make treatment recommendations. To highlight the confusion - a placebo-control study published last week contributes to the growing body of data showing no difference between laser therapy and placebo. However, another study published last week, which did not have sham controls, demonstrated improvements in both vaginal health and sexual function as well as remodeling of the vaginal tissues by increasing vaginal tightening and strengthening pelvic floor structures. In short, the official verdict is still out, but it might help you, and if it does, it's worth it. Unfortunately, the treatment is expensive (~$1000 per session with 3-5 recommended) and has to be repeated every 6-12 months (one session) since vaginal atrophy is a condition that continues to worsen as you age. A final word of caution if you choose laser therapy - skip the locations offering "vaginal rejuvenation" in favor of seeing a trained gynecologist.
Next time we will talk about other interventions that might help get your sex life back on track. Much research remains to be done to address women's sexual health, but there are many options available to you now. Don't let anyone tell you it's just part of getting older. Sex is important, and possible, at all ages.
Feel free to post any questions or requests for discussion of other topics in the comments section.
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