How Menopause Affects Sexuality

This article was written for Prosayla, the patient information site offered by ISSWSH, the International Society for the Study of Women’s Sexual Health. Links to Prosayla and to the ISSWSH website are provided below.

The Prosayla site contains a wealth of information about sexual health and sexual challenges, including medical conditions and pain. ISSWSH offers a nationwide directory of providers with expertise in sexual health and sexual difficulties.

GENERAL DISCUSSION

For anyone with ovaries, the stage of life known as menopause will come along sometime between the late 40s and mid 50s. Some of the early symptoms can even be seen in the late 30s. This is a time of profound physical, psychological and hormonal changes, with potential major effects on sexuality and sexual expression.

Prior to menopause, most ovaries produce estrogen (the most potent female hormone) and progesterone in a regular, rhythmic cycle organized around ovulation and the menstrual period. As the menopause approaches, this rhythm begins to be lost, and many aspects of normal functioning (like mood, sleep, energy, and sex drive) may be affected. Eventually the ovaries stop making estrogen and progesterone altogether, though there is a small amount of estrogen produced via other pathways in the body. Testosterone, which is produced lifelong, declines as well, as part of an overall trend with age. The menopausal transition takes 4 to 5 years on average. Menopause has officially arrived when there have been no menstrual periods for a year; the time leading up to this event is known as the perimenopause.

With the loss or sharp decline of estrogen, progesterone, and testosterone, physical changes occur in “estrogen dependent” tissues such as the vulva, vagina, clitoris and urethra. The hormone shifts as well as the aging process bring changes in body shape and usually some amount of weight gain, which can challenge body image and self-esteem. Mood changes can be abrupt and can cause friction between intimate partners as well as disruption in daily life. Some of these changes will ease with time, as the body and brain adjust to the lower hormone levels, but some, especially the physical changes, may not.

SIGNS & SYMPTOMS

There are many potential symptoms of menopause. Few people will display all of them, but most will have at least some:

Hot flushes, night sweats, disturbed or restless sleep (often sleep onset is good, but there may be early a.m. awakening and inability to get back to sleep); irritability, fatigue, sudden sadness, difficulty maintaining focus or motivation, decreased sexual desire.

Irregular menstrual periods, with variation in the timing, amount, and length of flow. Eventually, periods stop completely. Importantly, pregnancy is still possible in the perimenopause, and if it is not desired, contraception should be used until one full year after the last menstrual period.

Thinning and drying of the labia minora, vagina and vestibule. Tightening of the vaginal opening. Less ability to control the flow of urine, especially with coughing or sneezing. Increased chance of urinary infections. (Collectively, these changes are known as the genitourinary syndrome of menopause, or GSM). Weight gain of 5-10 lbs, usually around the waist. Thinning of head and body hair; thinning and drying of skin. Overall loss of muscle mass and muscle tone.

There may be diminished genital sensation, vaginal penetration may become painful, and orgasm may be reduced in strength and may take longer to experience.

CAUSES

Erratic and declining production of estrogen, progesterone, and testosterone. General changes of aging in skin, muscle tone, body mass and fat distribution.

AFFECTED POPULATIONS

Women (and transgender men) past the age of 45, though the age range is wide. Anyone who has had surgical removal of the ovaries prior to menopause, unless hormone therapy has been provided.

RELATED DISORDERS

Other conditions that can arise at this time and may need separate treatment include lichen sclerosus of the vulva, irritable/overactive bladder, pelvic floor muscle spasm (vaginismus or hypertonic pelvic floor disorder), and more general medical conditions like low thyroid function, hypertension and diabetes. Studies are inconclusive on the question of whether depression is more prevalent in menopause.

DIAGNOSIS

Menopause is a clinical diagnosis. That is, it is made on the basis of the whole “clinical picture” of age, menstrual pattern, symptoms, and sometimes physical exam. Blood tests for hormone levels can be useful but can also be confusing, since there will be huge variations in estrogen levels, especially early in the perimenopause, when most patients are experiencing symptoms and coming in to be tested. Another commonly tested hormone, FSH (follicle stimulating hormone), which rises in menopause, will also fluctuate widely in the perimenopause. Thus a single hormone measurement is not very helpful.

If only genital symptoms like diminished sensation or pain with vaginal penetration are present, then a physical exam and focused pelvic exam are especially important to distinguish between menopause-related hormonal causes and other etiologies.

STANDARD THERAPIES

The most effective therapy for the signs and symptoms of menopause is some form of estrogen therapy. This option is much safer than is generally thought; the confusion is due to misunderstanding and misreporting of the results of the 2002 Women’s Health Initiative study by nonmedical news media. Both systemic (meant to treat the whole body and all symptoms) and local (used only on the vagina and vulva) forms of therapy are available. The local forms carry no health risks for the vast majority of people, and can be truly life-altering in their ability to relieve pain and restore moisture and elasticity to the vulvar and vaginal tissues. Local estrogen therapy can be used indefinitely, while systemic therapy is often recommended for five years or less. Both types of estrogen therapy require a prescription. If the uterus is still present, progesterone or one of its synthetic analogues will need to be prescribed along with any systemic (but not local) estrogen therapy. Some women will also benefit from a prescription of testosterone in small amounts, to achieve normal premenopausal levels. High doses of testosterone, such as those often found in testosterone pellets, may bring about testosterone levels in the male range and should be used with caution.

An additional hormonal therapy option for GSM is intravaginal DHEA (dehydroepiandrosterone), a sex steroid produced by the adrenal glands. The prescription medication Intrarosa contains DHEA.

A nonmedication approach to GSM is provided by laser skin treatments like the Mona Lisa Touch procedure. Though long-term effects of laser therapy are not yet known, short-term results are promising.

A new class of medications, targeting KNDY neurons in the brain, provides effective relief of hot flushes without the use of hormones. Fezolinetant is the first such agent to have been approved by the FDA.

Some individuals may also obtain relief of hot flushes with other nonhormonal prescription medications. These include some antidepressants from the SSRI and SNRI classes, and gabapentin.

Many nonprescription therapies are also available for menopausal symptom relief, ranging from herbs to dietary supplements to lifestyle measures to alternative treatments like acupuncture. A full discussion is far beyond the scope of this article; indeed, whole books have been written about nonprescription treatment options. Some resources are listed below.

In general, with relief of menopausal symptoms (whether with the passage of time or with the use of hormonal or other therapies) comes improvement in mood, sleep, energy level, and therefore sexual desire and sexual enjoyment. However, if there have been changes of GSM, these are usually permanent and will need to be treated over the long term.

In order for enjoyable sex to be possible, whether self-pleasuring or partnered, it is important to first eliminate any pain. This might require a local (topical) form of hormone therapy, or simply the use of a good lubricant. Silicone based lubricants are long lasting, body friendly, and do not dry out or become sticky. Some people do well using food-based oils like coconut oil, while others find these oils alter their vaginal bacterial balance. Others will prefer water-based products. Organic options are available. In general, petroleum-based products like Vaseline and Aquaphor, as well as soaps or perfumed wipes, should be avoided as they can irritate the sensitive vulvar skin.

Once pain and lubrication have been addressed, there may still be the challenge of diminished genital sensation. Some individuals will find that commercially sold “warming” gels help to enhance sensation, but these should be used with great caution (best to start with a tiny amount) since they also can be irritating. Others will find that this is a good time to explore vibrators for a different type and intensity of stimulation. Many also find that other sex toys like a dildo or anal plug can produce new and pleasurable sensations. It can be fun to try out some new options, whether alone or with a partner. Several excellent websites exist to help understand the choices available. More information is included at the end of this article.

With orgasm (and often erection, for those whose partners have penises) becoming less reliable, it can be very empowering to shift the sexual script from a goal-oriented one focused on mutual orgasm, to a pleasure-oriented one focused on mutual enjoyment. There is no “right” or “only” way to have sex!

The psychological changes around the time of menopause can be difficult for many individuals and can impact sexuality in a variety of ways. On the one hand, our culture prizes youth and attractiveness, so older women may feel unattractive or even invisible. On the other hand, there is new freedom from pregnancy worries, and the power of self-knowledge. Older women often know better what they want and like, and may care less what others think. They have gained resilience over the years. This helps as they navigate changing social and family roles with aging, and sometimes the loss of a long-term partner to death or disability.

Finally, a word about desire, another topic that has been the subject of whole books: it is important to understand that in later life, especially in a long-term sexual relationship, is common to not feel desire that arises “out of the blue”, as many people do in their teens and twenties (this is called spontaneous desire). However, desire can certainly arise in the right context: a partner offers appreciative words or affectionate touch; partners plan a time and setting to enjoy unhurried sex; or the use of role playing, fantasy or erotica (written or visual) may awaken desire. This is called responsive desire, and it is the norm at this stage of life.

It may seem at first like all the changes associated with menopause would spell the end of quality sexual experiences. However, the majority of older adults still enjoy sexual activity and indeed, many express greater satisfaction with their sexuality than they did in their youth. They feel less pressure to perform and more freedom to both receive and give pleasure. More and more is being understood and written about sexuality in this “better half” of life.

INVESTIGATIONAL THERAPIES

As noted above, fezolinetant was just approved for relief of hot flushes, in a new category of medications targeting specific brain neurons. More new medications will no doubt appear. Sometimes it takes awhile for them to be covered by insurance plans.

SUPPORT AVAILABLE

With an estimated 1.3 million women entering menopause each year in the U.S., chat and support groups abound, whether as part of formal organizations like MeetUp and LinkedIn, or as informal friend groups. Many of the below resources can also be helpful.

RESOURCES

Menopause in general:

The Menopause Society, www.menopause.org The professional members of this society conduct much of the U.S. research on menopause and publish their results in the peer-reviewed journal Menopause. The site provides general information as well as position statements on subjects like hormone therapy and GSM. Includes a tool to find a certified menopause practitioner.

American College of Obstetricians and Gynecologists, www.acog.org This is the professional association of OB/GYN physicians. Their site includes resources on a host of reproductive health topics. FAQs about menopause and aging are provided.

Corinna, Heather. (2021).What Fresh Hell is This? Perimenopause, Menopause, Other Indignities and You. New York: Hachette Books. A humorous but very medically accurate and complete treatment of menopause. One of the few LGBTQ inclusive books on this subject.

Alternative therapies:

Women’s Encyclopedia of Natural Medicine, Tori Hudson, N.D., McGraw Hill Professional, 2007

The Wisdom of Menopause, 4th edition, Christiane Northrup M.D, Penguin Random House, 2021

Sexuality in later life:

Our Better Half, podcast with Jane Fleishman, PhD: www.ourbetterhalf.net

Price, Joan. (2011). Naked at Our Age: Talking Out Loud About Senior Sex. New York: Seal Press. A wonderfully frank and positive discussion about the reality and joy of sex in later life. The author has also published on sex after grief and loss.

Enhancing the sexual experience:

www.OMGyes.com , website devoted to women’s sexual pleasure.

www.early2bedshop.com : as well as a wide variety of products, the company offers curated product pages for “seasoned lovers”, transgender women, and people with fatigue and mobility issues.

www.liberator.com : offers padded furniture and wedges for support and comfort, as well as toys.

www.marrieddance.com : Christian sex toy website, no nudity on the site

Nagoski, E. (2015). Come as you are: The surprising new science that will transform your sex life. New York, NY: Simon & Schuster.

As described in the title, this book covers the recent research about the anatomy and physiology of sexuality. With a focus on women’s sexuality, the book investigates the ways that each person’s sexuality is unique and the importance of understanding sexuality in context. In a readable, accessible format, Nagoski’s book is enlightening, applicable, and research-based.

REFERENCES

Andersen, Nicholas J.; Parker, Jessica L.; Pettigrew, Susanne; Bitner, Diana Less (2022). Validation of the Menopause Transition Scale (MTS). Menopause. 29(7):868-876.

Bińkowska M, et al. (2019). Position statement by Experts of the Polish Menopause and Andropause Society, and the Polish Society of Aesthetic and Reconstructive Gynaecology on the medicinal product Intrarosa®. Prz Menopauzalny. 2019 Dec;18(3):127-132 (In English)

Cappelletti, Maurand, and Kim Wallen (2016). Increasing women’s sexual desire: The comparative effectiveness of estrogens and androgens. Horm Behav. 2016 February; 78:178-193.

Chlebowski, Rowan T. MD et al. (2020). Association of Menopausal Hormone Therapy With Breast Cancer Incidence and Mortality During Long-Term Follow-up of the Women’s Health Initiative Randomized Clinical Trials. JAMA 324(4):369-380.

Davis, Susan R. et al (2019). Global Consensus Position Statement on the Use of Testosterone Therapy for Women. J Sex Med 2019 Sep;16(9):1331-1337

Faubion, Stephanie, and Kingsberg, Sheryl, et al. The 2020 Genitourinary Syndrome of Menopause position statement of the North American Menopause Society. Menopause 2020; 27:9, 976-992.

Johnson, Kimball, et al. (2023). Efficacy and Safety of Fezolinetant in Moderate to Severe Vasomotor Symptoms Associated With Menopause: A Phase 3 RCT. J Clin Endocrinol Metab 2023 Jul 14;108(8):1981-1997

Menopause- StatPearls- NCBI Bookshelf: https://www.ncbi.nlm.nih.gov/books/NBK507826

The North American Menopause Society 2017 Hormone Therapy Position Statement Advisory Panel. (2017). The 2017 hormone therapy position statement of the North American Menopause Society, Menopause: The Journal of The North American Menopause Society 24(7), pp. 728-753.

Shifren JL, Monz BU, Russo PA, Segreti A, Johannes CB. Sexual problems and distress in United States women: prevalence and correlates. Obstet Gynecol. 2008 Nov;112(5):970-8

Shifren JL, Zincavage R, Cho EL, Magnavita A, Portman DJ, Krychman ML, Simon JA, Kingsberg SA, Rosen RC. Women's experience of vulvovaginal symptoms associated with menopause. Menopause. 2019 Apr;26(4):341-349.