Sex and the menopause

This article is written by Spiced Pear Founder Dr Angela Wright and was first published as a guest article on Gen-M In the chair across from me at the menopause clinic, my patient had started crying. I glanced up and studied her face, giving her time to order her thoughts and to try and articulate […]

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This article is written by Spiced Pear Founder Dr Angela Wright and was first published as a guest article on Gen-M

In the chair across from me at the menopause clinic, my patient had started crying. I glanced up and studied her face, giving her time to order her thoughts and to try and articulate the wave of emotion she was experiencing.  She was one of the oldest women I has seen that day, well into her seventies and referred in to discuss vulval pain and itch that had been plaguing her for years. I had just examined her, and found the tell-tale pale and shiny skin, and tight vaginal opening that revealed significant atrophic vaginitis.  This isn’t an unusual finding in a woman of her age, or in the women we see in the clinic. When we go through menopause, we lose some of the oestrogen moderated adaptations that keep us able to resist infections from, and prepare us for, sex. More than that, oestrogen gives us thick and springy vaginal walls that open in readiness for penetration. It helps keep the female erectile tissues healthy and responsive. It lets us lubricate for sex. It lets it feel good when we are touched in the right way.

Like a lot of women of her age, the lady now crying in front of me had been through her menopause without making much fuss. The arrival of hot flushes and disturbed nights was not something one really talked about, let alone reached out for help with. HRT existed, of course, but the newspapers at the time were full of stories that had made her nervous about it.  She had gritted her teeth through the worst of it, thinking it would all be finished with soon enough. And indeed, for her, it was. What no one had explained to her, however, was that the changes she was experiencing in her vulval skin might reach a point of no return if she took no action. Over the years she had been given steroids, thrush creams and a few short courses of oestrogen – but no one had taken the time to explain to her what was happening, or why.

I gently examined her and talked to her about the fact that after menopause, the lining of the vagina and vulva thins significantly. It loses its stretch. The blood flow to the pelvis drops, further adding to the deterioration of the structures therein. Our ability to respond with pleasure to sexual touch reduces – with us needing more intense stimulation to register the same touch that would have aroused us in our younger years. The pH of the vagina increases – oestrogen holds it at about 4.5, a slightly acidic environment that discourages the growth of bacteria and therefore helps us resist infection. After menopause we lose that defence and urine infections become more frequent. As the ligaments and tissues holding our pelvic organs in place get weaker, we can experience prolapse of the uterus, or of the bladder and bowel pushing down into the potential space of the vagina. The bladder changes too: weaker and less well-fed by blood supply, we become more prone not just to infection but also to urinary frequency and stress incontinence.  There is a great correlation between urinary problems and sexual dysfunction scores: it’s pretty hard to enjoy sex without being able to relax and let go in response to touch. Women who are afraid of leaking urine during sex find it very hard to let go – and so sexual pain, difficulty in climaxing and arousal problems correlate with the prevalence of lower urinary tract issues.

When the tears subsided, she spoke. She told me how envious she felt about younger women, who now had access to a better knowledge of their bodies and sexual pleasure than she had ever had.  She explained to me that she felt real regret that not only had she missed out sexually because of this in her younger years, she was now feeling intense grief for the permanent closure of that door. I could prescribe oestrogen cream now and the itch and discharge would likely improve: but the other changes were more difficult to reverse.  She was angry that not one of the doctors that she had consulted about this issue had thought to discuss her sexuality with her.

There is a deep and entrenched view that somehow, sex and sexuality are the exclusive preserve of the young and beautiful. This is often mirrored in the health professionals dealing with this age group. The era of Viagra has perhaps shifted us on a little, but in my experience what tends to happen is that conversations between doctors and women of menopausal age and above tend to focus mostly on reducing sexual pain. Very little is done to suggest that they aim for more than simply a “tolerance” of sex. And yet – good sex is so, so good for us.

Study after study proves this. A Swedish Study in 1981 showed that people who stopped being sexually active at a younger age, died younger. The Caerphilly Cohort Study in 1997 showed people having more than two orgasms per week had half the risk of cardiac death.

Enjoyment of sex is a significant predictor of longevity in women – calculated to equate to an extra 4.28 years of life. Quantity seems to be more important to men: for women, but quality is key. Many studies correlate healthy sexuality with longer, healthier lives. In the “Let’s talk about Sex” study looking at older people’s views on sex and sexuality; sex, sexuality and the expression of sexual identity are recognised as central components of quality of life and well-being. Older people are no exception to this rule. Research consistently shows sexuality is still important to adults over 65 years of age. And it is not all about penis-in-vagina sex. Kissing, fondling and petting are positively associated with satisfaction with life, and feeling emotionally close to your partner.

We have so far to go with shifting the views of health professionals and helping this generation of peri- and post-menopausal women to have better sexual function as they age. Yes, the teaching doctors get about sex is patchy at best. Attitudes around the importance of the sex lives of their patients need to change. It was only my training in Clinical Sexology that allowed me to fully recognise how little my medical training had prepared me to deal with this aspect of my patient’s lives. But the evidence is very clear that if we keep women healthy enough that they can still feel and enjoy sexual touch, we will also improve wider health outcomes. 

Studies show the tendency of women to tolerate painful sex and keep quiet about it starts early: about a third of women aged 16-35 regularly have pain with penetrative sex, but such is the need to feel “normal”, that they still keep sexually active despite this. This sentiment is echoed over and over again in my clinic room: It really hurts.  Can I have something to help? My partner still wants to have sex. I’m not bothered about it for me, though.

There is a lot to unwrap in statements like that. The New View Campaign points out that, unlike our male counterparts, being able to have access to sexual satisfaction goes far beyond a woman having the “working parts”. Social, relational and cultural pressures are hugely relevant to women: discrepancies with the power balance, or the expectation within relationships; prevalence of sexual violence or coercion; religious and cultural norms; lack of access to adequate education about our own body and physiology; access to a partner who is sexually skilled and considerate. These things are beyond the scope of an article like this: but it would be remiss not to point out they all have a role in putting the sexual problems of mid and later life into better context.

Women need to know it is ok not to only seek to reduce pain. We have to educate about sexual pleasure too.  Especially by explaining to menopausal women about the role of hormones – or moreover, the loss of them – on their libido, their ability to dream and fantasise about sex, and to feel and to respond to sexual touch. Until we do this, we can’t hope to change things much.

We need to reach women directly to educate them about the need to proactively take choices about managing their post reproductive years, effectively spent in a hormone-deprived state that we were never really supposed to survive so many years into. As life expectancy has extended, we have longer and longer to live through with a sub-optimal hormone balance. A change in our lens is needed. We were never really supposed to live a third of our lives this way. So, now that we do: how do we reach women and let them know that they need to take active choices.  How do they want this stage to look?  How do they want to feel?  What do they want to be able to do? 

Systemic HRT has a risk:benefit balance that is different for every individual (though in my experience most women still falsely perceive the risks will outweigh the benefits for them.  This is much less often the case in reality). Topical oestrogens are a far less complicated equation: they have very clear safety data, and can be used in the vast majority of women without fear of increasing their risk of cancer or blood clots. NICE guidance is very clear that symptomatic women should be offered these local hormone creams for as long as they need them, and yet I still see so many women who have never been made aware that this is not just possible – but preferable.  

Women need to know that it is not just ok to ask for lubricants and oestrogen cream to stop itch and sexual pain. They need to understand that with ongoing use of topical oestrogen, and ongoing sexual activity – partnered, or solo, it matters little – they can maintain blood flow to their pleasure tissues and keep them healthy and responsive. In doing this, they’ll also bring blood to the nearby bladder and pelvic floor muscles and uterine ligaments and keep all this healthier too. They will improve their overall number of years of life – and also improve the life in those years.

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Throughout this website, we use the term women when describing people who experience hormonal symptoms. However, we acknowledge not only those who identify as women require access to menopause and hormone health information. For example, some trans men, non-binary people, intersex people or people with variations in sex characteristics may also experience menopausal symptoms and PMS/PME or PMDD, and we warmly welcome everyone who needs this support in our clinic.

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