Menopause & sexuality.
For most people, at least some aspects of sexuality decline with age, such as level of desire or frequency of sexual activity. There are many biologic and non-biologic reasons this happens, including a person's general well-being and health, lifestyle, as well as interpersonal and psychosocial factors (like the quality of a relationship, or mental health issues). Popular culture tells us that many women lose interest in sex during or after menopausal transition, but those ageist and sexist messages aren't supported by good scientific research. The NWHN wants you to have the facts about menopause and sexuality, and to offer a few helpful remedies.
Is diminished sexuality inevitable during menopause?
Contrary to popular misconception, the menopausal transition and resulting drop in estrogen levels does not doom a woman to entering a sexual desert. Women can feel varying degrees of change in sexual function during menopause, but these changes are not absolute, constant, or irreversible. Both men and women experience declining sexual desire and activity with age, (1) and studies show that factors connected to one's relationship and partner play an important role in levels of desire and the frequency of sexual activity. (2)
Every woman, menopausal or not, has her unique approach to, and expectations about, sexuality. Desire and dysfunction vary from woman to woman. Some menopausal women may not engage in sexual activity due to a lack of desire and, in the absence of partners' or personal expectations, may pass through menopause without any complaints about sexuality. Others may feel desire but face difficulty in sexual satisfaction due to pain or vaginal dryness. Some women don't experience any changes at all that they associate with menopause.
The longest-running study of women's experience with aging looked specifically at the issue of changes in sexual functioning, in fact. The Study of Women's Health Across the Nation (SWAN), which follows women who were between 42 and 52 when the study began, examined the relative contribution of menopause and other factors on changes in sexuality. (3) In a six-year follow-up of study participants, researchers found that: (4)
* Menopausal women can and do enjoy sexual activity.
* The menopausal transition does not independently cause women's diminished sexual arousal, reduced sexual activity, and lower levels of physical pleasure, although it can contribute to these issues.
* Vasomotor menopausal symptoms of hot flashes and night sweats are not directly related to sexual functioning. When these menopausal symptoms cause distress and interfere with sleep, however, they can indirectly contribute to psychological factors that affect sexual functioning.
* Vaginal dryness, which is one of the most common symptoms of menopause, can cause vaginal pain and reduced physical pleasure during penetration, which may lead to diminished sexual desire during menopause.
Factors that may affect sexuality
As noted, several factors can affect a person's experience and sexuality, including:
* General health and well-being:
Cardiovascular disease, obesity, joint problems, and urogenital conditions (like urinary incontinence and pelvic surgery) may impact comfort with sexual activity.
* Lifestyle factors: Exercise and a healthy diet protect against conditions such as cardiovascular disease and diabetes that can impact health and sexuality. Several strong research studies have found that being physically active is associated with higher levels of sexual engagement and enjoyment.
* Interpersonal factors: The quality of relationship with a partner, and the partner's general and sexual health, can contribute to the sexual experiences and satisfaction. The Melbourne Women's Midlife Health Project (MWMHP) found that relationship factors and prior sexual function and were more important determinants of sexual responsiveness than women's estrogen levels. (5)
* Psychosocial factors: Women who are depressed or have higher anxiety levels have less optimal sexual functioning. The Women's Health Initiative's (WHI) observational study found that--irrespective of the stage of menopause--higher reported levels of social support (like having friends) leads to higher levels of sexual engagement and enjoyment. (6)
Dealing with vaginal dryness and pain
Of the factors that can affect sexuality in menopause, vaginal dryness is the one that is most directly connected to women's experience of pleasure. There are ways to manage vaginal dryness that can make sexual activity more comfortable again.
During the menopausal transition, women's estrogen levels decline, which can result in reduced amounts of natural vaginal secretions. It can also result in a tightening of the vaginal opening and/or narrowing and shortening of the vagina itself. Both the lack of lubrication and change in the body's shape can cause pain and discomfort during penetration (called "dyspareunia").
Lubricants ("lube") can make many kinds of sexual activity, from fondling to intercourse, more comfortable. (7) Moreover, regular sexual activity--either alone or with a partner--can help maintain vaginal lubrication and elasticity. Some women like to use lubricants when needed, and find creative ways to make lubricants part of sex play. Others like the convenience of a once-a-day product, like Replens.
Some women turn to medical treatment for vaginal dryness and discomfort. Estrogen vaginal creams are approved for this use and are effective for most women. They also have the benefit of putting control over the dose and timing into the woman's hands.
Some women find creams messy, however, and prefer other products like vaginal rings that contain estradiol. Compared to menopause hormone therapy provided by pills or patches, which have powerful and occasionally dangerous effects throughout the body, lower dose estrogen products designed for vaginal use have little effect on the rest of the body. They do have some effects, however, so women who've had hormone-sensitive cancers should use these products only with caution. (8) And, all women should watch out for symptoms of systemic effects, like breast tenderness or uterine bleeding, and see their doctor right away if these symptoms appear.
The NWHN is often asked if we oppose the use of vaginal hormone therapy--probably because we're so well-known for our critique of menopause hormone therapy and its dangerous effects, which can include breast cancer and cardiovascular disease. The NWHN does not oppose vaginal estrogen therapy, as long as women are informed not only about alternatives but also about how to monitor themselves for any sign of problems. (It is important to note that systemic menopause hormone therapy is not associated with more or better sex. (9))
Is there a pill for desire?
When sildenafil (Viagra) was approved to treat erectile dysfunction in men, many women argued, only halfjokingly, that gender equity demanded a similar pill for women. (Viagra itself doesn't work in women. (10,11,12)) Drug companies wholeheartedly agreed and poured millions of dollars into the search for a drug for women. After many failed attempts to find a drug for women, one is on the market. Flibanserin (Addyi), the "female sexual dysfunction" pill was approved by the FDA for in August 2015, over the objections of the NWHN and other feminist and consumer health activists.
Viagra helps men who already want to have sex but who have physiological problems; it is taken before sexual activity and increases blood flow to the penis. Addyi, on the other hand, changes women's brain chemistry to help them want to want to have sex; it has to be taken every day. Unfortunately, Addyi doesn't seem to work very well: after adjusting for placebo, only about 10 to 12 percent of women in the drug's clinical trials reported even minimal benefits from the drug. (13) And, the drug doesn't make it easier for women to achieve orgasm or make sex more enjoyable for either partner.
The NWHN believes that there are too many unresolved questions about Addyi's serious side effects (which include sudden prolonged unconsciousness and dangerously low blood pressure), and too little evidence that it works, to recommend it to anyone. (Learn more about Addyi at: www.nwhn.org/addyi)
There are many factors that can drive changes in sexuality as women age. We advise women not to approach menopause with any preconceived fears of losing their sexuality or ability to experience sexual pleasure. Rather, we encourage women to be aware of the different issues that can affect their lives, including their sexuality, and explore ways to address these changes during and after the menopausal transition.
(1.) Lindau ST, Schumm LP, Laumann EO, Levinson W, O'Muircheartaigh CA, Waite LJ. A study of sexuality and health among older adults in the Unites States. N Engl J Med 2007; 357(8): 762-764.
(2.) Huang AJ, Subak LL, Thom DH, Van Den Eden SK, Ragins Al, Kuppermann M, Shen H, Brown JS. Sexual Function and aging in racially and ethnically diverse women, J Am Geriatr Doc 2009; 57(8): 1362-1368.
(3.) Longitudinal Changes in Sexual Functioning as Women Transition Through Menopause: Results from the Study of Women's Health Across the Nation (SWAN). Menopause. 2009; 16(3): 442-452.
(4.) Correlates of Sexual Satisfaction Among Sexually Active Postmenopausal Women in the Women's Health Initiative-Observational Study. J Gen Intern Med 2008; 23(12):2000-2009.
(5.) Hess R, et al. Association of lifestyle and relationship factors with sexual functioning of women during midlife. J Sex Med 2009; 6(5): 1358-1368
(6.) Hayes R, Dennerstein L. The impact of aging on sexual function and sexual dysfunction in women: a review of population-based studies. J Sex Med 2005; 2(3):317-330.
(7.) Van der Laak, JA, de Bie LM, de Leeuw H et al.The Effect of Replens[R] on Vaginal Cytology in the Treatment of Postmenopausal Atrophy: Cytomorphology Versus Computerized Cytometry. Journal of Clinical Pathology 2002; 55(6): 446-451.
(8.) Suckling JA, Kennedy R, Lethaby A, Roberts H. Local estrogen for vaginal atrophy in postmenopausal women. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD001500.
(9.) Hemminki, Elina et al. "The Effects of Postmenopausal Hormone Therapy on Social Activity, Partner Relationship, and Sexual Life Experience from the EPHT Trial." BMC Women's Health 9 (2009): 16. PMC.
(10.) Basson R, Mclnnes R, Smith MD, et al. Efficacy and safety of sildenafil citrate in women with sexual dysfunction associated with female sexual arousal disorder. J Women's Health Gend Based Med 2002; 11:367-377.
(11.) Berman JR, Berman LA, Toler SM et al. Safety and efficacy of sildenafil citrate for the treatment of female sexual arousal disorder: a double blind, placebo controlled study. J Urol 2003; 170:2333-2338.
(12.) Basson R, Brotto LA. Sexual psychophysiology and effects of sildenafil citrate in estrogenised women with acquired genital arousal disorder and impaired orgasm: a randomized controlled trial. BJOG 2003; 110:1014-1024.
(13.) National Women's Health Network (NWHN), Fact Sheet: Top Ten Things to Know About Addyi," Washington, DC: NWHN, 2016. Online at: www.nwhn.org/wp-content/uploads/2015/10/NWHN_Addyi_Fact_Sheet_P2.pdf