Sexuality and Menopause

Menopause is the time when the production of hormones, chiefly estrogen and progesterone, dramatically decreases, bringing an end to the menstrual cycle and fertility. While many women welcome the cessation of menstruation, they may not have realized how strongly it was connected to their self-image of being feminine and sexual.

Women enter menopause in diverse ways. There may be a sudden onset due to surgery. Hot flashes and erratic menstrual periods signal the approaching change for some. Others may have noticeable mood swings, depression, or insomnia. If these symptoms are severe enough estrogen is prescribed. Embarking on Estrogen Replacement Therapy (ERT) or Hormone Replacement Therapy (HRT) plunges a woman into the debate over whether the acclaimed benefits of taking ERT/HRT including protection from heart disease and osteoporosis, outweigh the risks of getting breast and uterine cancer, blood clots, and high cholesterol.

In the midst of that debate sexuality issues often get lost. Yet these issues may be of more immediate concern, particularly; the light to extreme vaginal dryness which results in painful sex, and diminished sexual desire. These symptoms do not effect all women, just as many women never experience hot flashes. But when they occur they are inescapable and complex to treat.

How much personal or professional help a woman gets with her changing sexual feelings and physical responses may depend on how comfortable she is with her own sexuality. The degree to which she has felt sexually safe, accepted, and desired during her growth from girl to woman will effect how satisfactorily she can voice her needs to her doctor and sexual partner.

Low estrogen levels decrease blood flow to the vagina setting up a series of falling dominoes. Decreased lubrication can make vaginal friction and penetration uncomfortable or painful. Without lubrication a woman may think that she is not sexually turned on, which can lead her to question her affection for her partner. The discomfort or pain may be severe enough for her to avoid sex and even physical affection if it might lead to sex. If masturbation was a pleasurable part of her sexuality (whether partnered or not) she may think she's lost interest in herself! There may even be a feeling of shame that the lubrication she took for granted as part of being a sexy woman is gone, and thus the whole sexy woman is gone too. It compares to the shame that a man feels as his erections become less reliable with age.

It is likely that if a woman's sexual history includes sexual abuse, or a long or short-term unsupportive or incommunicative partner in the bedroom, her sexuality will fare no better with the changes menopause brings about. For example, unresolved relationship issues including money, balance of power between partners, difference in child rearing styles, and involvement with extended family, can all have an impact on a couple's sexuality. If one partner in the relationship (either male or female in a heterosexual one) carries intense anger or contempt for the other, withholding sex becomes a powerful weapon and may already be part of an established pattern; a lose-lose situation for both.

In our youth -oriented society, the menopausal woman is encouraged to restore what she is losing through ERT or HRT. Certain hormone treatments (estrogen, progesterone or testosterone) usually assuage menopausal symptoms such as vaginal dryness and hot flashes. Some women even report restoration of energy, memory, improved skin condition, and overall well-being. What is still up for grabs is the optimum dosage, length of time, and best hormonal combination to take in order to maximize the benefits while reducing the risks. Just as women weighed and chose the risks, benefits, and side effects of birth control pills, IUDs, and other birth control devices we do so again with ERT/HRT.

And like birth control ERT/HRT is highly political. There is a growing number of wonderful books on menopause, many of which reflect different biases. Often an author shows preferences for or against ERT/HRT, and for or against synthetic, plant or animal-derived compounds. In some books, sexuality takes center stage, and it seems to make perfect sense to take hormones to restore sexual vigor and interest. In others you might conclude that you would be making a bargain with the devil by risking cancer and blood clots for a good lay.

Some authors accuse "the feminists" of portraying hormone therapy as a conspiracy of the male dominated medical model that considers menopause to be a disease, and a conspiracy of the billion-dollar drug industry that has profited from ERT/HRT sales. While there is objective truth to these interpretations, a woman may not know herself what drives her choices; concerns for her health, or anger at the drug industry or the male dominated medical establishment. What about the "naturalness" of the most widely prescribed estrogen compound which is derived from the urine of pregnant mares? A vision of barns of pregnant mares being milked for their urine could make a woman become a vegan! (Don't laugh, soy is a good source of estrogen). I don't even want to think about how testosterone might be collected!

If vaginal dryness is the only problem, the many water- based lubricants from the drug store may suffice. If they don't eliminate pain during sex, a locally applied estrogen cream taken in specific doses and for specific periods of time can thicken vaginal walls and restore vaginal secretions. If a woman is uneasy about estrogen absorbed systemically by pill or patch, estrogen cream allows her to choose the lowest dose for maximum effectiveness. Vaginally applied estrogen cream should not be used as a lubricant and should not be applied before heterosexual sex, as estrogen absorbed through the penis has been associated with tumor growth in men. Condom use is sometimes suggested for full protection in such cases.

While estrogen (with or without progesterone) may resolve hot flashes and vaginal dryness, many women on ERT/HRT still report no restoration of a libido or sexual desire. The literature is confusing as to estrogen's impact on sexual desire.While many writers would agree with Susan Love's statement that "no correlation has yet been found between estrogen and sexual interest", 1Lonnie Barbach reports a Yale University study showing that "90 percent of the women who had experienced a lack of desire before the study reported an increase in desire after being treated with estrogen for three to six months."

I believe that what is being confused is the difference between sexual drive and sexual desire. The desire to have sex may be there, but the drive or visceral urge may not be. A woman may desire to engage in sexual relations anticipating good feelings, relaxation after orgasm, or increased closeness with a partner, yet still not feel the sexual urge in her groin or however she has been accustomed to experiencing being "horny". As with the gradual disappearance of natural lubrication, the loss of the sexual urge may make a woman, and/or her partner, believe that she no longer wants sex, or doesn't want it with her partner. For many women, this happened long before the onset of menopause, but for those for whom this is a new loss, it is deeply missed.

Judith Reichman argues that "desire is a function of expectation and memory, and if we remember negative experiences we can lose our desire".3 Acute symptoms of menopause (hot flashes, insomnia, moodiness, etc.) certainly can erode sexual desire. To the degree that estrogen ameliorates these symptoms, desire may return if a woman is willing to engage in sex in the absence of the sexual urge. She may not have the same sexual experience she used to have ten or twenty years ago, but that is more a function of aging, not of menopause. Many women report that while they may not feel like having sex, once they become open to a willingness to be intimate they can usually get turned on. This is a good example of using the other sex organ, the brain.

What about testosterone, the male sex hormone credited with male sex drive? Women produce testosterone at about ten per cent of male levels. While production levels of total hormones decrease in menopause, it has been pointed out that women's testosterone levels increase proportionally as estrogen levels decline. While testosterone in various forms (pills, shots, pellets, patches, and creams) is prescribed for women with absent sex drive, there is less long-term research than for estrogen on the safety and efficacy of dosage size and length of use. For some women it has worked well, others have experienced only short-term benefits. There is concern that long term use in large doses can adversely affect cholesterol levels and the liver, and produce secondary male sex characteristics like a lower voice, and increased body hair. Caution and close physician monitoring are recommended with testosterone use.

For some menopausal women, it is their partners whose sexual interests have changed. It is common enough for men to experience erection failure or impotence due to aging or the side effects of drugs for chronic medical conditions. They may feel so much shame and performance anxiety that they would rather forego sex altogether than be treated. Experimenting with drugs like Viagra or devices like penile implants after prostate cancer surgery, for example, can stress a couple's sexual life, beyond living with and surviving a life threatening disease. Open communication and couple's counseling might help a couple through such periods.

There are also many psychosocial factors that can at least temporarily deaden sexual drive and activity. The many social, familial, and professional changes midlife women experience may at first be felt more strongly as losses than as opportunities for new growth: children leaving home; the stopping of the biological clock for women who didn't have children; new single status through divorce or death of a partner; diminished ability to compete professionally with younger women, or workplace pressures to retire; new dependence or death of a parent; health problems associated with aging. We need to do the necessary grieving for these losses before we can move on to the transformational opportunities they can offer us.

Nothing helps more than knowing you are not alone. And you are not. Check out the growing number of books on menopause, share these issues with your partner, and your friends. Start a menopause support group. We are on a bridge to the next stage of our lives, and the discoveries we make now will brighten what comes next.

REFERENCES

Barbach, L. " The Pause: Positive Approaches to Menopause", New York: Signet Books, 1994.

Love, S. "Dr. Susan Love's Hormone Book", New York: Random House, 1997.

Reichman, J. "I'm Too Young to Get Old", New York: Times Books, Random House, 1996.

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