Let’s talk about Sex (and the menopause)

sex and the menopause

Sex in mid-life. It should still be on the table, right?

A wide range of studies, across a variety of cultures, highlight that women believe that sexual activity is important throughout midlife. Yet research also shows that we’re having less sex. John Hopkins Medicine states that half of women in their 50s continue to have sex with this number dropping to 27% of women by their 70s.

Why is this? 

Sexual difficulties, common at any age, often increase through midlife thanks in large to changing hormone levels – principally lower levels of oestrogen and testosterone. Together these hit your sex life – reducing sex drive (libido), creating lower motivation and fatigue in general and also impacting the health of your vulva and vagina.

But it isn’t a done deal. There are a number of ways to address these issues to get that spring back into our steps and enjoying sex. Because, let’s not forget, while a slower paced sex life can suit some, for others it can have a negative impact on their relationships as well as their overall wellbeing and self-esteem.

Low libido

Many women get to a point where sex is pretty far down their priority list and sex drive is diminished. 

The causes of diminished libido are multi-factoral and include changing hormone levels (which can impact your pelvic health and make it harder to orgasm), psychological factors such as self-esteem and simply the busyness of life itself

To start with hormone levels. 

A drop in oestrogen can impact the health of your vulva and vaginal with a knock-on effect on sexual desire. Replenishing your oestrogen via HRT has been shown to support libido. There are also herbal routes such as taking gelatinized Maca root. 

Lower testosterone levels also impact libido. Testosterone can be boosted by lifestyle measures such as by building muscle via weights or resistance training, eating healthy fats, reducing sugar, and sleeping well. It is also key to watch out for stress.  After menopause the adrenal glands are responsible for producing background levels of sex hormones including testosterone. Modern life and stresses can impair the adrenal glands’ ability to do so.

If these routes do not help, some women consider replenishing testosterone levels. This is something to be discussed with your healthcare provider and is rarely available via the NHS. It should be considered only once oestrogen has been shown to not help with symptoms. Your testosterone levels will be monitored to ensure they do not go too high and to watch out for side effects (which can include hair loss, acne, mood changes).

It’s important to not underestimate the influence of how we feel on our sex drive. 

The menopausal years occur, for most women, at a time when home, work and relationships can be stained. It’s not uncommon to experience poor body image and loss of self-esteem as well as low mood, depression and anxiety. None of this is exactly conducive to romance and intimacy.

If you are finding it hard to shift these feelings, discussing these concerns with a GP or a counsellor can help. 

Vaginal Dryness (Vulvovaginal Atrophy)

Our vaginas benefit from natural lubrication produced by glands at the cervix. During sexual excitement, a different set of glands (the Bartholin’s glands) produce extra moisture to aid sex. 

Vaginal dryness, however, is common through menopause with studies showing up to 60% of women reporting this symptom.  The key contributing factor is the decline in oestrogen levels.  Vaginal dryness can result in discomfort and irritation through to bleeding and painful penetrative sexual intercourse. For many women it can be quite distressing. 

As a first step, avoid anything that exacerbates dryness or irritates such as bubble baths or highly perfumed soaps and shower gels. If dryness is particularly an issue during sex, take more time to get aroused giving the Batholin’s glands time to produce maximum lubrication.

There are also a number of treatment options that really can help:

Vaginal moisturisers and lubricants:

These are suitable for women with mild symptoms, can be obtained over the counter and are applied topically.

Vaginal Moisturisers can be used regularly for non-hormonal relief of vaginal dryness. They reduce discomfort and irritation by rehydrating dry mucosal tissue.

Vaginal lubricants are beneficial for women whose dryness is primarily a concern during sex. They reduce friction, and help alleviate discomfort. They can be applied to the vagina, vulva or penis prior to / during sexual activity.

There are a lot of vaginal products on the market, but their chemical composition varies and some can cause detrimental effects like vulvovaginal irritation, soreness, infection (eg. Candida) due to unphysiological pH, osmolality and additives. In Potter & Panay’s 2020 review into the use, efficacy and safety of vaginal lubricants & moisturisers, they recommend that women should be directed toward products that are as ‘body-similar’ as possible to vaginal secretions in terms of pH and osmolality eg Yes Vaginal Moisturiser and Yes lubricant. 

Local oestrogen:

While systemic (whole body) oestrogen (HRT) can help with symptoms it can be contraindicated for some or not a preferred choice for others. Local oestrogen, just applied in the vagina, is an option available to all as there are no increased risks of breast cancer nor risk of blood clot

Local oestrogen comes in the form of a cream, gel, a vaginal ring or pessary. Options can be discussed with your GP and, for some post menopausal women, can be bought over-the-counter at the pharmacy in the form of ‘Gina’.

Painful Sex (Dyspareunia)

17-45% of postmenopausal women say they have experienced painful intercourse. Commonly this is caused by vaginal dryness (see above) but there can be other reasons behind this pain. 

It is possible that the pain is caused by sensitivity or tension of the pelvic floor muscle itself. Tension and sensitivity of the pelvic floor muscle is often multifactorial but if you are experiencing painful intercourse and lubricants / moisturisers are not helping then ask your GP for a referral to a pelvic health physiotherapist. They will be able to help diagnose the cause and provide a bespoke treatment program. 

Just because you’re menopausal does not mean that your sex life is over.  Quite the opposite, it can be a time for new sexual discovery, exploration and enjoyment. Don’t forget - if you’re perimenopausal, remember to use protection as you can still get pregnant! 

Sexual activity and intercourse however shouldn’t be uncomfortable or painful. The nature of these symptoms can cause embarrassment so women under report it but I’m here to tell you – PLEASE, if you are experiencing any symptoms including vaginal dryness, stinging, swelling, chaffing, or painful sex please discuss it with your GP or pelvic health specialist. This is not something you need to suffer in silence, there are many good treatments available. 

Written by Emma Brockwell, pelvic health physio
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