Michael Abrahams | Menopause and sex

Menopause is a natural process. However, the changes that occur during this time have the potential to affect some activities, and sex is one of them.

For some menopausal women, sex is more enjoyable as they do not have to worry about pregnancy if they do not wish to conceive. However, issues with sex are common during this phase of a woman’s life. Up to 50 per cent of women of menopausal age report experiencing discomfort or pain during sex (dyspareunia). Other complaints include decreased desire and sexual responsiveness, including difficulty in achieving orgasm.

One of the hallmarks of menopause is a dramatic decline in the level of oestrogen, a female sex hormone produced by the ovaries. This hormone is essential to maintain the structure and functioning of the vagina. Prior to menopause, the vagina has thick walls with rugae, which are folds that look like accordion-like wrinkles, that allow the organ to expand to accommodate a penis or a baby. However, during menopause, with the drop in oestrogen, the vaginal walls become thinner and drier (vaginal atrophy), and the rugal folds flatten, impairing vaginal expansion. Oestrogen deprivation also contributes to decreased blood flow to the genitalia. When blood flows more slowly to genital organs during sexual arousal, sensitivity to these areas may be reduced. These changes, combined with the resulting decreased lubrication and the lower collagen level that comes with ageing, have the potential to make the menopausal vagina less receptive to penetrative sexual activity, resulting in reduced pleasure, and discomfort or even bruising and tears. In addition, the changes in the quantity and quality of vaginal secretions can alter the vaginal microbiome, causing an increase in vaginal pH, elevating the risk of developing bacterial vaginosis, a common vaginal infection characterszed by a malodorous discharge

HELPS MAINTAIN STRENGTH

Oestrogen also helps maintain strength in the pelvic floor muscles and the bladder. So low oestrogen levels can result in urinary stress incontinence, resulting in urinary leakage with coughing, jumping, and other types of physical activity, especially when the bladder is full. The dryness from decreased oestrogen can predispose menopausal women to burning with urination and urinary tract infections. These urinary symptoms can also be barriers to sexual fulfilment.

Oestrogen deprivation, along with the above-mentioned declining levels of collagen, can also affect the appearance of the vulva, causing the labia to become saggy. In some women, the labia minora actually disappear. Lower oestrogen and progesterone levels also alter the hair growth cycle, causing pubic hair to become sparse.

The hormonal changes of menopause do not only cause changes to the pelvis and genitalia but also the brain. Declining levels of oestrogen can reduce sexual desire and arousal. As ovarian function declines during menopause, the ovaries also produce less testosterone, which can not only contribute to mood changes and fatigue, but also decreased libido. Depression is also more common in menopausal women than in younger females, and this can also negatively affect libido.

Low oestrogen levels can also contribute to anatomical changes remote from the pelvis, such as sagging of the breasts and weight gain, especially with accumulation of belly fat. These changes, in addition to those in the pubic area, may adversely affect some menopausal women’s self-confidence and affect their enjoyment of sex.

MULTIFACETED APPROACH

Addressing sexual issues arising during the menopause requires a multifaceted approach. Communication with sexual partners is very important, letting them know what symptoms are present and discussing plans to address them. Lifestyle changes such as getting enough sleep can help to improve the sex lives of menopausal women. A study published in 2021 in Menopause: The Journal of the North American Menopause Society found that women who slept poorly were nearly twice as likely to report issues such as lack of sexual interest or pleasure than women who got adequate sleep.

Exercise, including pelvic floor exercises such as Kegel exercises (clench-and-release exercises that strengthen the muscles of the pelvic floor) and stress management will contribute to better health and have the potential to improve the sex lives of those who practise these. Masturbation can improve mood, enhance sleep, and maintain vaginal health. A study conducted by the Kinsey Institute found that 36.2 per cent of menopausal women interviewed reported experiencing improved symptoms through masturbation. Orgasm and massaging of the vaginal walls increases blood flow to the genitalia, and as with masturbation, the use of sex toys may also be of benefit for this reason. A sexual aid called Eros can also be used to treat women with disorders of sexual arousal. The device increases lubrication and sensation and can increase the number of orgasms in women who use it.

Using vaginal moisturisers and personal lubricants can assist in alleviating discomfort caused by vaginal dryness. Lubricants should be water-based as oil-based lubricants are more likely to predispose to infection, and they may affect the integrity of condoms if they are used. Vaginal oestrogen preparations, in the form of pessaries, creams, gels and rings are very useful in counteracting the drying effects of oestrogen deprivation on the vaginal walls. Oestrogen can also be delivered as pills, injections, patches, implants and pellets to manage not only vaginal, but also other menopausal complaints. Depending on the symptoms, progesterone and testosterone may also be delivered in various combinations and in different forms. Non-hormonal drugs such as ospemiphene and prasterone can also be used vaginally to treat atrophy and the discomfort it causes.

Medical procedures are also available to enhance sexual function during the climacteric. The “O-Shot,” or Orgasm Shot, a non-surgical treatment using a patient’s own blood to stimulate vaginal rejuvenation and enhance sexual function, has benefited many women. The MonaLisa Touch, another non-surgical procedure, uses carbon dioxide laser to remove dry skin, which stimulates collagen and elastin production, thereby restoring vaginal lubrication and elasticity and relieving discomfort. And of course, there are surgical procedures that can be used to address anatomical issues with the vagina (vaginoplasty) and labia (labiaplasty).

Menopause should not put a pause on a woman’s sex life.

Michael Abrahams is an obstetrician and gynaecologist, social commentator, and human-rights advocate. Send feedback to columns@gleanerjm.com and michabe_1999@hotmail.com, or follow him on X , formerly Twitter, @mikeyabrahams.