A leading women’s sexual health expert wants you to know that sex can be enjoyable for women during and after menopause.
Dr. Sheryl Kingsberg, Ph.D.
Member, HealthyWomen Women’s Health Advisory Council
“Women of all ages want to and can remain sexually satisfied well into old age,” says Dr. Sheryl Kingsberg, Ph.D., a member of the HealthyWomen Women’s Health Advisory Council. She notes that while reproductive life may be over with menopause, sexual life can still thrive.
After menopause — the time after a woman’s menstrual periods permanently stop and she can no longer get pregnant — the body makes less of the reproductive hormones, estrogen and progesterone.
Sexual concerns
Dr. Kingsberg, who’s also chief of the division of behavioral medicine at University Hospitals Cleveland Medical Center, says there are four categories of sexual concerns for women: desire, which is a woman’s appetite for sex; arousal, which is both in a woman’s mind and genital arousal; orgasm; and genitourinary syndrome of menopause (GSM), caused by a reduction in estrogen.
Dr. Kingsberg says loss of desire is most seen in women ages 45 to 65. That’s likely because by the time a woman is in her 50s, her testosterone level’s about half of what it was in her 20s. Other health issues, like clinical depression, can impact desire too.
GSM is characterized by changes in the genitourinary tract, including vaginal dryness, painful intercourse, and reduced lubrication.
“It’s not just the vagina. The whole urogenital tract is impacted by that loss of estrogen,” she says. “The tissue in the vulva, without estrogen, loses elasticity. The vagina itself can narrow, the tissue becomes thin and kind of dry, and it can easily get injured. That makes sex very painful.”
Additionally, without estrogen, the bacteria in the vagina changes, resulting in the pH balance being off. The microbiome changes too, due to the loss of estrogen. A reduction in good bacteria can result in an increased risk for painful urination and urinary tract infections.
Treatment
Dr. Kingsberg, the former president of The North American Menopause Society, estimates 50-80% of women experience symptoms of GSM, but the condition is not talked about the way hot flashes and night sweats are.
“Women may not realize, ‘oh, this is about menopause. Maybe I should talk to my gynecologist or my primary care provider about this,’” she says. “Often they will suffer in silence, not even knowing because we don’t talk about it enough.”
She says GSM is simple to treat, including using water-based lubricants, local estrogen or DHEA hormone therapy, or taking oral medicines. There are other potential treatments such as Co2 laser treatments, but double-blind trials are needed. Pelvic floor physical therapy and behavior therapy could help a woman’s anticipatory anxiety about pain related to GSM symptoms.
Regarding treating loss of desire, she says there no FDA-approved pharmacologic options for postmenopausal women. But two, which are approved for pre-menopausal women, can be used off label for postmenopausal woman.
Testosterone may be a treatment option too. Right now, it’s only approved in Australia for the treatment of hypoactive sexual desire disorder. Dr. Kingsberg is a co-author on a report and says, “it’s a safe and effective treatment for postmenopausal women with hypoactive sexual desire disorder.”
Empowering patients and providers
Dr. Kingsberg calls on healthcare providers to get comfortable addressing and treating sexual concerns. Explaining treatment is not a one-size-fits-all, she encourages women to talk to their doctors about treatment options. “Because we do have treatments whether it’s psychotherapy, pharmacotherapy or some combination, women should not suffer in silence, whether it’s low desire, arousal, or GSM,” she says. “They should be asking, and if their provider is uncomfortable, find another provider.”
