How common is it for women to begin having sexual problems during the perimenopause years?
It’s quite common, but not necessarily exclusively for physiological reasons in perimenopause. It’s also just about that stage of life. When you think about women around the age of 45 moving into their 50s (common perimenopause years), they’re managing a lot of really complex psycho-social stressors.
For example, they might have kids at home that they are caring for, often teenagers that have their own hormonal landscape. Then, women are very often the primary caregivers for elder family members – both their own and their partner’s.
It’s also often a stage of life where people are taking on more responsibility in their careers, where they are maybe managing a lot. So, there’s a lot that contributes to fatigue, to stress. And we know that fatigue and stress are significantly going to decrease interest in sex.
At the same time, women’s hormones are often radically fluctuating, correct?
Yes, there is a changing hormonal landscape. The decrease in estrogen can contribute to a decrease in sexual desire. Fluctuating levels can also cause weight gain during this stage of life, particularly around the middle part of women’s bodies. So, there’s that body image as well – internalized feelings of shame about one’s body, less feeling of one’s own sense of attractiveness or sexiness – that can then contribute to not wanting to be seen or to engage in a sexual way.
I also think that how we are socialized around middle age and sex is a problem. I’d say it’s changing, but there’s not great representation of what middle-aged pleasure and sexuality can look like on social and mass media. So, I encourage people to change their algorithms on social media so it’s more body positive, more representative of the beauty across the lifespan.
Sometimes, the menopause transition can affect mental health. Can you talk about how that can raise sexual health issues?
Yes, it can, and low sexual desire is also a significant feature of major depressive disorder itself – part of what’s called anhedonia, where people have a loss of pleasure in most things that previously brought pleasure. So, I have to determine: Is it also that someone isn’t having pleasure in most areas of life? That might suggest to me that it’s not just a low-sex drive problem, but a bigger mental health concern.
The drugs used to treat these disorders can also sometimes create issues, correct?
There are several psychiatric medications that can cause low sexual desire. Most of the SSRIs (selective serotonin reuptake inhibitors, such as Prozac and Zoloft), which are very commonly used for the treatment of depression/anxiety, are known to have sexual side effects. Though I’m not a prescriber, I do routinely ask about what psychiatric medications people are on, because it may be worthwhile for them to work with their psychiatrist to maybe change their medications.
What other menopause-related issues can cause women sexual problems?
As people go through the menopause transition, there are sexual health concerns specifically related to genitourinary changes, so vaginal dryness, more likelihood of injury to the vagina, more tearing. There’s more likelihood of pain with penetrative vaginal intercourse, and we know that when there’s pain with sex, when it’s not consensual pain that’s part of someone’s play but physical pain that’s unwanted, it’s going to significantly decrease desire and longing for sex.
Do you ever suggest hormone therapy for sexual issues?
I do encourage people to work with their OB/GYNs to look at what might be possible given their health profile with respect to hormone replacement therapy. Another thing that is not widely known is that there are vaginal estrogen therapies, so it’s not systemic hormone replacement but local to the vagina (ointments, rings, suppositories). These can improve the overall environment of the vagina, decreasing injury, bruising and dryness.
The other thing I recommend, in addition to a lubricant product that can be used in the moment of sexual play either with oneself with toys or with a partner, is vaginal moisturizer. There are some really great products on the market that folks can find at local drug stores that I recommend using at night a few times a week.
What other problems in the bedroom do you see in this age group?
Sometimes when I see people reporting sexual problems with menopause, I try to determine if concerns or challenges already existed that, with the physiological changes, were just amplified. It’s not uncommon that there was already a lack of interest, or a lack of novelty in the relationship.
For many women, novelty is a really important part of sex. Often women will share with me: Well, you know, I don’t have this problem of low desire when I go on vacation. People often will attribute that to leaving the stressors at home, but there’s also the novelty of being in a new environment.
People have to work intentionally in their day-to-day lives to have that kind of novelty. Do something different, where you get to be silly, try something new, have different kinds of conversations. That can help to bring that sense of playfulness into the sexual relationship as well.
Do you sometimes see patients who went into early menopause for some reason?
Yes, that’s another important group of patients beyond those experiencing life course menopause that benefit from our guidance: patients who undergo menopause abruptly, sometimes unexpectedly. Total hysterectomies (ovaries removed) or some cancer treatments, for example, can put patients into immediate menopause. That experience can be startling and acutely distressing. These patients, who tend to be younger, don’t have time to mitigate or learn to work around the changes.
Do you ever find partners who do not view the importance of sex life in the same way?
Yes, that’s when I talk about sexual autonomy. I ask: Is this person coming to me because sexual pleasure and sexual play is important to them; do they still want this to be part of their life? Or have they made peace with the idea that it’s not that important – that it isn’t really what they want or need in life anymore – but they feel like they should. Sometimes they feel like there’s something wrong with them, or there is discordance in the marriage or relationship because the partner does find it important.
So that’s a more nuanced conversation. And sometimes my work is around helping with coming to self-acceptance that, yeah, it’s totally fine. There are other ways to share intimacy that are not just sexual or are not just vaginal penetration. My bigger question for people then is do you have a sense of fulfillment? Do you have a sense of purpose? Do you have pleasure in your life? That’s what is most important.
