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Sexually Transmitted Infections - A Concern for Menopausal Women

Although menopausal women no longer need to worry about unwanted pregnancy, the risk of sexually transmitted infections (STIs) remains. STIs are infections spread by sexual activity, especially vaginal intercourse, anal sex, genital touching, oral sex, or manual sex. STIs are caused by bacteria, viruses, or parasites. The eight most common STIs include four curable infections (chlamydia, gonorrhea, syphilis, and trichomonas) and four that are treatable but incurable (hepatitis B, herpes simplex virus, human immunodeficiency virus (HIV), and human papilloma virus (HPV)). Couples who engage in penetrative sex have a higher risk of STIs than those who do not. Same-sex female couples have even lower risk, but some risk exists with any sexual contact.

According to the Centers for Disease Control and Prevention (CDC), among Americans over 55, the number of cases of gonorrhea rose 164%, cases of syphilis rose 120%, and chlamydia rose 86% between 2014 and 2018. Multiple factors likely are involved in the increased STI prevalence:

  1. One study found the divorce rate for the U.S. population over 50 doubled between 1990 and 2010. Divorce rates in other developed countries are following the same trend - Japan saw a quadrupling of divorces during the same period. The divorce explosion means there are more unpartnered midlife women, many of whom are interested in meeting new sexual partners. At the same time, there has been a significant increase in the number of women who choose to remain unpartnered throughout their lives.

  2. Most midlife women, even those with new sexual partners, perceive themselves to be at low risk of acquiring a STI. The perception appears to be residual from when they were in long-term, monogamous relationships and/or an incorrect belief that serial monogamy (that is, moving from one committed partnership to another) is safer than having non-monogamous sex with the same number of partners.

  3. Midlife women don't use condoms as often as they should. Some women don't use condoms because they are no longer concerned about unwanted pregnancies and don't consider STI prevention. Some women are reluctant to bring up condom usage to their new partners because of embarrassment over talking about sex, perceived and actual resistance to condom use by midlife men (sometimes because they associate it with erectile dysfunction), and a perception that condoms are a young thing, and not for someone their age.

  4. A history of physical or emotional abuse by previous partners sometimes leads women to be reluctant to bring up STI prevention and testing with new partners because they fear it may cause conflict.

  5. Midlife women do not receive regular education about STI prevention, leading to them not being up-to-date about current risks and preventative steps. Healthcare providers can subscribe to the stereotype of the midlife woman as an asexual being. As a result, they may not screen their midlife patients for STIs, ask them about their sex partners and STI prevention, or provide information to them about prevention to the same extent as their younger patients. Some women also often believe it is the doctor's responsibility to initiate the discussion so they fail to advocate for their own care.

  6. Some midlife women subscribe to the stereotype that only a certain type of people get STIs. The bacteria and viruses that cause STIs do not discriminate based on socioeconomic status, job history, race, or any other factor. I have treated women of all ages, races, and socioeconomic class for STIs. I have diagnosed STIs in women who have been partnered for decades, as well as those who have had sex one time with one person. My patients include those who were infected by friends or long-term partners and those who have multiple one-night stands. Midlife women should realize that STIs are quite common - it's not cause for shame. Approximately 15 million people in the U.S. develop a new STI each year, and 1/3 of all Americans have had an STI in their lives.

  7. The availability of drugs like Viagra for men with erectile dysfunction and more awareness and treatments for the genitourinary syndrome of menopause (GSM), which has made sex more comfortable for midlife women, contribute to increased sex, and therefore STIs, among midlife women and men.

Although some STIs are easily treated, others are not, and some STIs, left untreated, can cause serious health issues. For example, there are treatments for HIV and hepatitis C, but they are difficult diseases to manage. Untreated chlamydia and gonorrhea can cause few symptoms but can cause pelvic inflammatory disease, which results in scarring of reproductive organs leading to chronic pelvic pain. (In reproductive age women, chlamydia and gonorrhea can cause infertility.) The incidence of drug-resistant gonorrhea continues to rise - there is now only one class of antibiotics that can treat this infection.

Proper use of condoms and dental dams can significantly reduce the risk of STI transmission. Use a condom every time you have anal, vaginal, or oral sex. Condoms are available in multiple sizes and types, but you should avoid lambskin (natural) condoms since they don't provide as much protection. Female condoms can be used as an alternative, particularly in situations in which the male partner resists using a condom. Dental dams are latex or polyurethane sheets used between the mouth and vagina or anus during oral sex. Condoms, female condoms, and dental dams can be bought in most drug stores, grocery stores, and online.

Another way to reduce transmission is to get regular screening. If you plan to have a new partner, both of you should request STI screening from your doctor. Re-testing is recommended in 3-6 months since some infections (e.g., HIV) may not be detectable immediately after infection. In the meantime, you should use a barrier method, like those described above. Only after you have screening results for both partners, and you are both committed to a monogamous relationship should you engage in unprotected sex. You also should talk with your doctor about the possibility of getting vaccinated for HPV if you intend to have multiple new partners. The HPV vaccine is recommended for women under 45 but also may be appropriate for older women, even if you have previously been diagnosed with HPV - the vaccine will provide protection against different strains of the virus. Untreated HPV can lead to cervical cancer in women and other cancers in men. Your doctor also might recommend that you get vaccinated against hepatitis B to protect against that infection.

Menopausal women, particularly those with new sex partners, should take extra care to keep their vaginal tissues healthy. All menopausal women will experience GSM to some degree in their lifetime. Dry, thin vaginal tissue is more prone to tearing during penetrative sex, which provides another point of access to infectious agents like HIV. Your doctor can prescribe medications that will help with GSM. You also can do some things at home. Vibrator use has been shown to increase blood flow and decrease GSM symptoms. Regular, copious use of lubricant during sex will reduce the likelihood of vaginal tearing. Make sure you give yourself the time you need to become adequately aroused prior to penetrative sex.

Finally, communication is one of your most valuable tools against STIs. Talk with your doctor, even if it's uncomfortable. Talk frankly with your partner. Don't be afraid to ask about your prospective sex partner's sexual history and current practice. Tell them that you'd like for both of you to get STI screening prior to sexual contact and to use barrier protection. And ask yourself if you really want to have sex with someone who doesn't care about your sexual health enough to agree to testing and barrier protection?

Sex after menopause can be fabulous. You no longer have to worry about unwanted pregnancy, your kids are (almost) out of the house, and you've reached a level of confidence where you can love your body for what it is and tell your partner exactly what you want. Get out there and do it! Just remember to take a couple of easy steps to reduce your risk of STIs.

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