Sexual problems and the menopause – problems at the coalface

INTRODUCTION

In March of this year, I was asked to present a talk, under this title, to the delegates at the IPM Annual scientific Meeting in Manchester. I felt a bit of an interloper: I am a COSRT trained doctor, and although I attended IPM seminar groups with Dr Cath White for about a year (and hugely enjoyed the experience), I never quite got out of my bad habit of trying to fix the problem.

I did ask whether it was ok to stand up at an IPM conference expounding the virtues of the biopsychosocial approach. However, Cath kindly pointed out that there is no ONE way to approach any sexual problem. This is very true – and those of us working in General Practice will appreciate the fact that what helps most is having a range of tools and approaches to help women struggling with the sexual impacts of their menopause.

GPs tend to have careers that wind through more specialties than most. This usually means we have a wide range of clinical experience to draw on, all of which can usefully be applied to solving sexual problems. I have picked up useful tools from each of the teams and patients I have worked with in my own career.

I am a GP, who worked in a hospice for a decade, before doing a two year COSRT-based Diploma in Clinical Sexology and completing the ESSM Advanced School of Sexual Medicine and membership exam, to obtain my Fellowship of the European Committee of Sexual Medicine. I found I was regularly using my new skills with menopausal women, so went on to complete the British Menopause Society’s Advanced Certificate in Menopause Care. I now work two days a week in General Practice in North Yorkshire, a day a week in a Menopause/PMDD/Psychosexual clinic and spend the rest of teaching and in private practice.

I used my talk to argue that as GP’s, we are uniquely placed to ask about sexuality: if sex is important to our patients (and it is!), then it should be just as important to us. Sexual problems can be associated with lots of shameful feelings – and shame needs light and air to lose its potency.

We need to feel confident to ask about problems and validate and normalise the experience of changing sexuality through our life cycle. We may not always have the answers to the problems – but by providing space to explore what is happening, we can help our patients to start to formulate a way forward.

WHY SEX IS PART OF OUR JOB – AND HOW TO TAKE THE RIGHT APPROACH TO IT

One of the reasons we can carry a lot of shame about perceived issues with our sex lives is that we often have very little idea of how we measure up to others. What is “normal” when it comes to sex?

In the UK at least, we do have some facts and figures to draw on to help us know what everyone else is up to. The NATSAL study (National Survey of Sexual Attitudes and Lifestyles) is undertaken every few years and provides us with a snapshot of what is happening in the bedrooms across the country.

Natsal 3¹ shows us that health status correlates with frequency of recent sexual activity, and confirms that vaginal, oral and anal sex are still enjoyed by men and women well into later life. For example, 19% of 65-74 year olds have given or received oral sex in the last year. 8% of women aged 45-54 had had anal sex in the last year. For reference – about 14% of adults in the UK describe themselves as vegetarian. Understanding what is common in sexual behaviour is important.

1 in 6 adults reported their health impacting their sex life in the last year, but only 1 in 5 women in this group had sought help from a medical professional about this. 51% of female respondents had experienced problems with sex, and 11% described themselves as “worried or distressed” about their sex lives.

How do these numbers compare with how often the subject is raised in your surgery? It is easy to begin to understand that many of our patients are suffering in silence. The onus shifts to us to make these conversations possible.

This is important because sex can be considered a marker of health and quality of life. Research has shown repeatedly that sexual activity, quality of sex life and interest in sex are positively associated with health in middle age, and beyond². Sexual function closely relates to life satisfaction.

Whereas in men, the quantity of sex is important, for female bodied individuals rate the quality of their sexual interactions as most critical³. There is even research suggesting that individuals having 100 orgasms annually have a 3-8 year increase in their life expectancy!⁴

NOTICE YOUR ASSUMPTIONS

My medical training was very heteronormative, and it was implicit that monogamy was the standard relationship model. My sexological training blew those ideas out of the water: it is important to remember your own training in (and experiences of) relationships and sexuality, may not mirror those of your patients.

For example – solo sexuality is just as important to partnered sex for many – so your single, widowed or divorced patients may still keenly enjoy their bodies and libido, and value being asked about it even though they are not partnered. We may also have many unconscious sexual scripts that govern the amount and types of sex we consider “normal”, and we need to check these biases and assumptions. Remember that menopausal women are a changing demographic, with many more entering second, third or even fourth relationships, navigating this new territory with a changing body and sexual response. Their worries about sexual function may be different to those in long term partnerships, where loss of desire may have different causes.

REMEMBER TO BE TRAUMA-INFORMED

1 in 4 of our female patients, and 1 in 6 male, will have a history of sexual trauma⁵. Many more will have experienced trauma associated with medical procedures, or childbirth. We need to consider this when we examine our patients. The Survivors Trust recently launched the “Check with Me First” campaign⁶: reminding health professionals that the simple act of asking “Do you find being examined difficult?” and “What can I do to make it easier?” can mean the difference between triggering our patients and increasing their sense of bodily autonomy and confidence in seeking help in future from medical professionals.

WHY WE NEED TO LOOK AT SEX DIFFERENTLY: A BIOPSYCHOSOCIAL LENS

The DSM criteria for sexual problems have been criticised for not looking at the wider picture – beyond our bodies -that impacts sexual health:

• Access to education about our bodies and our sexuality
• Access to help with our sexual health
• Cultural norms and freedoms
• Access to a skilled partner
• Access to a safe, noncoercive relationship
• Past experiences e.g. trauma, violence

Clinical Sexology is taught with a biopsychosocial model. Many of us will have been taught with a biomedical model: and when it comes to sexual dysfunction, the implication might be that “if the bits work, sex works”. But this misses what we instinctively know in practice: that patients’ lives, relationships and histories differ, and this impacts what they perceive as desirable. It impacts what treatments work.

The biopsychosocial model can be visualised like a Venn diagram: it combines what it is happening in a patient’s body, with what is happening in their mind and in their life and relationship. It is about understanding the context of the person and placing their problem within it. It can help to
ask three simple questions:

• What changes have you noticed in your body?
• How are you feeling in yourself?
• What’s going on in your life now?

SCRIPTS

I have already touched on the concept of social and sexual “scripts”: a term psychologists use for the unconscious framework of “rules” and “norms” that govern our beliefs and behaviours. We have lots of these where sex is concerned, and so do our patients.

We internalise information from society, friends, parents, media (and increasingly, porn) and religious teaching about how sexuality should work. Because most of us only get to know the truth of our own (and our sexual partners) sexual behaviours, they are what we have to draw on when considering what counts as normal (and what counts as a problem) in the following areas:

• Sexual repertoire
• Frequency of sexual activity and desire
• Monogamy as normal (and easy!)
• How sex changes with parenthood, illness, ageing
• Cultural norms and acceptability of sexual interests and practices

Like any bias, it is important to be aware of it. We all bring these scripts into the consultation – the patient, and us. Part of psychotherapeutic work can include examining these scripts, and whether they are still valid for us.

It can also be helpful to challenge scripts around how bodies work: especially female bodies. Many scripts exist around what “normal” heterosexual sex looks like – and perpetuate the idea that penetrative sex is the main event, and of more value than “foreplay”.

The persistence of this idea is responsible for the current orgasm gap in heterosexual sex. We know that 95% of men, and women, will climax within minutes when they self-stimulate⁷. Though the male orgasm rate stays high, the female orgasm rate drops to only 65% in heterosexual sex, and as low as 18% in casual heterosexual sex. By contrast, women who have sex with women report orgasm rates of 85%9. This is powerful evidence that shows how sexual scripts can affect sexual function: many women (and their partners) erroneously believe female orgasm is somehow difficult to achieve or should be easily achieved by penetrative sex. Despite Hollywood films and pornography tending to show women climaxing easily from penetrative sex, most sexological studies show that (significantly) less than 30% of women climax from penetrative sex alone. This demonstrates how explaining the inaccuracy of these common heterosexual scripts might immediately counter the feelings of shame around difficulty climaxing, for example.

THE FOUR PILLARS OF SEXUAL FUNCTION

The ESSM teach that healthy sexuality is built upon four pillars. Our sexual function (desire, arousal, climax), our sexual identity (the concept of being a sexual being), our sexual relationship (who we choose, or are able to express our sexuality with) and our sexual body (our wider body, used as a tool for sex – smell, touch, flexibility, erogenous zones etc). Anything that impacts one of these, can impact sex.

The menopause can affect them all.

CONSIDER THE 4 PILLARS OF SEXUAL FUNCTION

Anything impacting these can impact sex:

• Sexual Function: desire, arousal, climax
• Sexual Identity: the concept of being a sexual being
• Sexual Relationship: who we choose or are able to express our sexuality with
• Sexual Body: our body as a tool – with smell, touch, flexibility, saliva, erogenous zones, touch etc.

BIOLOGICAL CHANGES AT MENOPAUSE – SEXUAL FUNCTION & SEXUAL BODY

To understand the way menopause affects sex, it can help to start with a reminder of just how ingeniously adapted our bodies are for sex during our fertile years.

The vagina and vulva enjoy excellent blood supply, and the cells on the surface of the vaginal walls slough off and are replaced every four hours or so. This provides quick repair from the microtrauma of penetrative sex, and the glycogen rich cells provide the perfect environment for lactobacilli. They produce lactic acid to ensure the vaginal pH is kept low, discouraging infection.

The clitoris has nocturnal nighttime erections during our fertile years, similar to the penis in males. The spongy tissues are kept in a slightly hypoxic state, the purpose of the erections being in part to bring fresh oxygenated blood to the tissues and maintain their health and structure.

Our sex hormones are integral to both the central and peripheral pathways of sexuality. Sexual interest and receptivity tracks closely with when these hormone levels peak during ovulation. Oestrogen ensures better blood supply to breast tissues and the pelvis, maintaining the health of the tissues and sensory
nerves that receive touch.

As we enter perimenopause then menopause, hormones fluctuate wildly for several years before reaching new, permanently low levels. Testosterone, made by both the adrenals and the ovaries, falls off slowly over time: but women who undergo oophorectomy or sustain damage to their ovaries as a result of
chemotherapy or radiotherapy, will have a catastrophic drop in T. This has been shown to make sexual dysfunction more likely.

The loss of oestrogen and androgens has a profound effect on the genitals, pelvic floor and bladder.

Tissues thin by up to two thirds. This includes the bladder trigone and the external vulval skin. The sensory nerves become less sensitive. Stretch is lost. Lower blood supply leads to less lubrication and sluggish tissue repair. The loss of glycogen in the cells leads to falls in lactobacilli and a rise in vaginal pH. Infection becomes more likely. The biome changes, so the vaginal odour alters. Climax can become more difficult, or impossible. Sexual pain rates increase.

Bladder issues – continence problems, and recurrent UTI – become more likely, and there is a significant cross over between the presence of these issues and sexual problems. Women tend not to mention the impact of bladder leak on sex, and we tend not to ask. But being afraid of leaks or climacturia can significantly depress libido and sexual satisfaction.

WHAT ELSE COMMONLY IMPACTS SEX IN MENOPAUSAL WOMEN?

It is not just the direct impacts to the pelvic area that impacts sexuality in menopausal women.

Wider physical and emotional impacts affect sexual interest, energy levels, self-esteem, mood. Joint pains, hair and skin changes, flushes and palpitations and headaches all create circumstances where it can feel harder to access sexuality.

Our ageing bodies are also accumulating other health issues – and so are our partners. Male partner health remains one of the key factors impacting the sexual satisfaction scores of women in later life, and it is important to bear this in mind when considering the menopausal woman in the context of her life. Diabetes, heart disease, hypertension, depression, osteoarthritis, neurological conditions – all these conditions impact sex both directly and indirectly. The medications we prescribe for them also often impact sex too: and it is something we are rarely trained well in, and even less often tend to discuss with our patients.

Common culprits in prescribing are:

• SSRIs/SNRIs
• Opiates
• Antihypertensives – especially B blockers and ACE inhibitors
• Antimuscarinics
• Antihistamines
• Dopamine agonists/antagonists
• Hormonal contraceptives and hormone blockers
• GnRH analogues

CANCER SURVIVORSHIP

Women who are cancer survivors make up a significant proportion of menopausal women: they have often suffered the dual impacts of the existential and physical trauma of cancer diagnosis and treatment, then the ongoing effect of an induced menopause.

Symptoms can be particularly abrupt and severe in this subgroup, and they often feel little can be done as most will not be candidates for HRT.

It is estimated that about 19% of older people will be cancer survivors by 2030⁸. Sexual dysfunction is the third most prevalent symptom reported – after fatigue and loss of physical fitness.

Discussing menopause treatment in this subgroup deserves its own article – but there are many nonhormonal approaches, and the vast majority of this group will be safe to use low dose vaginal oestrogens. There are often many psychosocial impacts on sexuality, on top of the significant physical impacts of cancer treatment. My take home message would be to make space to discuss this with your patient, to normalise and destigmatise the issue. Up to 22% of couples will separate after cancer – the impacts on relationships and happiness can be very long reaching⁹.

HOW DOES TESTOSTERONE IMPACT LIBIDO?

This is a subject I get asked about a lot – and although there is evidence to support the use of testosterone in post-menopausal women with hypoactive sexual desire disorder and female sexual dysfunction, it is important to dig into what your patient is describing when she complains of “loss of libido”.

Libido is complicated – a true biopsychosocial issue, and although testosterone is important
in the central and peripheral pathways coordinating our sexual response, it is important to
recognise we rarely desire things that are painful or unrewarding. Ask what is happening with arousal, continence, lubrication. Ask whether climax can be achieved as easily as before. Ask if sex is painful. Find out what is happening with self-esteem, stress, sleep and relationships. Trauma can also be very relevant in this group, and several small studies have shown overlap and exacerbation of menopausal symptoms in
women with a trauma history.

There are many models of sexual desire, but the one I find most useful to draw on when I am discussing this subject with patients is Rosemary Basson’s Circular Model of Desire. She produced her model after studying how desire worked for women in long term relationships. She realised that desire was not always present first in arousal, and that there were many motivations for having sex. Some of these were “avoidance” motivations – such as fear of losing a partner, or a desire to prevent a partner from stopping loving us. Some were “approach” motivations – a wish for a positive outcome, such as pleasure, or emotional closeness, or the physical release of orgasm.

Basson realised that women could enter the cycle at any point – with arousal sometimes coming before desire to have sex was felt. She described women as “sexually neutral” – needing the right context, the right trigger or stimulus, and most importantly, the motivation or willingness to have sex. Without that willingness, the context or stimulus would not be enough.

HOW LIBIDO WORKS: MODELS OF SEXUAL DESIRE: BASSON

• Circular model – developed from particular focus on women in long term relationships
• Desire can be responsive or spontaneous, and come before or after arousal
• What makes someone want to have sex? No one reason
  • Approach motivations – emotional intimacy, attraction, engage in physical pleasure, express love
  • Avoidance motivations – a desire to prevent something i.e. partner leaving or for fear of not being loved
  • Certain stimuli may turn someone on & increase interest in having sex: tactile, visual, smell, sound
  • These stimuli initiate sexual arousal when all other conditions are met, including one’s willingness to engage in sex
  • In other words, turnons alone are not always enough for a person to have sex

What does this do to help us in practice? It reminds us that we must work at many levels to help someone regain sexual interest, and that for many women sexual desire works more responsively, than spontaneously. This means that although it is important to ensure women have adequate local and systemic oestrogen, and adequate testosterone for their bodies and brains to be able to works as well as possible, that there is much more that can be happening in their emotions and relationship, and expectations, that may make sex out of reach.

Positive reinforcement

Negative reinforcement

It is important to treat pain, loss of arousal, loss of continence and other issues that may affect a woman’s expectation that sex will be a positive and pleasurable experience. It is also incredibly important to look at what is in her head when she is having sex – distraction and dissociation detract significantly from arousal and enjoyment. Depression and anxiety are also significant in this regard.

Relationship safety and quality also has huge impact. Again – although we may not have solutions for all these things, it’s so important we make space to validate a woman’s experience and legitimise her concerns.

PSYCHOLOGICAL CHANGES SEXUAL IDENTITY

Our sexual identity, as previously described, is how we see ourselves as a sexual being. It is something that is fluid as we go through life and is often impacted by key shifts in our wider identity – things such as parenthood, divorce, illness and ageing.

The menopause can happen at a wide range of ages, but the loss of potential for fertility often leads to an emotional shift. For many women, menopause feels synonymous with ageing – and in our western society, this does not confer the status that it often can in different cultures. We are bombarded with
heavily youth-weighted images of beauty, and many images of sexuality and sex in the media are of young, slim bodies.

It can feel challenging to accept the physical changes of ageing, and the changes in skin, hair and body shape and firmness that may accompany this transition.

Many women feel a loss of safety in their bodies after serious illness, birth traumas, infertility or surgery: these issues should be considered potential traumas and they may need specialist support in order to process the impacts of this. Many cope with medical trauma by dissociating, and it can be this that makes it hard to feel safe afterwards.

Menopause can also accompany a role shift – often from mother to grandmother, or if we have become menopausal through illness, a shift to carer and patient. Relationship traumas such as infidelity, death
or divorce can also shift our sense of identity and need navigating with care and the right support.

Of course, many of these changes can be viewed as positively as well as negatively, but from the point
of view of sexual dysfunction at menopause, it can be useful to look at our patients with this lens in mind. Low self-esteem and shame cause cognitive distraction during sex, and this is associated with poorer sexual satisfaction scores.

Counselling support can be useful to provide the space to examine these feelings and challenge negative self-image.

SOCIAL CHANGES – SEXUAL RELATIONSHIP

There is insufficient space to adequately discuss all the relational issues that might impact sex – but as much of a patient’s sexuality can be experienced with a partner, it is important to consider this aspect when looking at a sexual problem.

Partner health – both general, and relating to sexual function, is obviously important and a common source of potential impacts on how a patient may experience her sexuality around menopause.

Desire for partner is also a very relevant issue – and one that we may hesitate to discuss openly with a patient. Esther Perel, a renowned relationship therapist, has written extensively on the paradox that can exist in many long-term relationships between the need for emotional intimacy, and erotic desire.

We are wired towards intimacy, sexually speaking, with research showing that there is often a greater physiological “investment” in a newer partner. This loss of novelty can inevitably present some issues for long term relationships that may be very relevant in our consulting rooms.

Whilst we don’t need to be able to explore or help resolve such issues, it can be useful to allow a patient to see that this is relevant and to understand that psychosexual counselling may be helpful.

Where there is desire discrepancy within a relationship, the loss of sex within the relationship can create a loss of all intimacy. Couples can stop going to bed at the same time or stop cuddling – for fear of any affection being seen as a “green light” for a sexual advance.

Facilitating communication here is key.

CONCLUSION – IS THERE A TAKE HOME MESSAGE?

There is no easy summary to make, other than perhaps to reiterate that our key role is to be curious and offer our patients the chance to discuss this aspect of their lives with us.

Understanding that sexual problems exist in a biopsychosocial context and feeling confident to explore what is going on a little with your patient, is perhaps the key thing. In general practice, it is hard to have the time to spend working through the details of a situation with your patient – so our key role is in asking the questions, validating the importance of the issues, destigmatising what is happening, and in helping our patients to become more conscious of what factors might be at play for them.

We can certainly be proactive about resolving some of the biological issues that are contributing to a problem – but by having a knowledge of the potential psychological and social factors that can create or complicate a picture, it allows us to hold a mirror up to our patients’ situations and help them to see how they may be able to act to improve things. We don’t need to provide all the solutions, just give permission and space to explore them safely.

REFERENCES

1. https://www.natsal.ac.uk/sites/default/files/2020-11/natsal-3-reference-tables.pdf
2. Forbes MK, Eaton NR, Krueger RF. Sexual Quality of Life and Aging: A Prospective Study of a Nationally Representative Sample. The Journal of Sex Research 2017; 54 (2): 137-148.
3. Nappi RE, Cucinella L, Martella S, Rossi M, Tiranini L, Martini E. Female Sexual Dysfunction (FSD): Prevalence and Impact on quality of life (QoL). Maturitas. 2016 Dec; 94: 87-91.
4. Davey Smith G, Frankel S, Yarnell J. Sex and Death: are they related? Findings from the Caerphilly Cohort Study. BMJ. 1997 Dec 20- 27; 315(7123):1641-4.
5. https://rapecrisis.org.uk/get-informed/statisticssexual-violence/
6. https://www.thesurvivorstrust.org/nhs-checkwithmefirst
7. Gurney K. Mind the Gap. London: Headline Home; 2020.
8. https://www.macmillan.org.uk/images/people-living-with-cancer_tcm9-283689.pdf
9. Reisman Y Gianotten W (eds). Cancer, Intimacy and Sexuality, A Practical Approach. Springer; 2017.