Expert Interview: Sex and Menopause
Here at Lisa Health we believe that knowledge is powerful and having the right knowledge can be life-changing. This is especially true when it comes to sexual health. Countless women experience significant changes in this area of life during menopause, which is hard enough without the added stress of figuring out how to address it and how to communicate with our partners about it. Luckily, we got to sit down with one of the leading experts on this very topic, Dr. Barb Depree, and ask all the tough questions. We believe the knowledge she shared will be both insightful and empowering for women facing these issues, and a reminder that you are not alone.
Lisa Health (LH): How does a woman’s sexual wellness typically change during menopause?
Barb Depree (BD): The term sexual wellness leads me to the discussion about vaginal atrophy. The most marked event of menopause is the absence of estrogen and its impact on a woman. Specifically, the greatest area of impact is on our genitalia. You have estrogen receptors everywhere in your body, but the area where the receptors are most concentrated is your genitals. The consequences of the decline in estrogen tend to be a loss of volume and shrinking of labia and vulva. Most women are going to experience progressive dryness and pain during sex starting with perimenopause. These issues will persist for the remainder of a woman’s life and will worsen without treatment.
LH: How common is sexual dysfunction in menopausal women?
BD: The majority of women will experience atrophy and pain during sex, and it can get progressively worse. About sixty percent of women’s symptoms over time will no longer be remedied by simply using a lubricant or moisturizer.
LH: How do changes in hormone levels during menopause affect sexual wellness?
BD: One of the big impacts of estrogen on the vagina is elasticity. With the loss of estrogen that elasticity decreases. If you think about what the vagina needs to have comfortable sex, a lubricant on its own may not be sufficient. Dr. Jim Simon once said that a healthy vagina is like a comfortable pleated skirt. My analogy for menopausal women is that five years into menopause your pleated skirt has turned into a tight pencil skirt. The vagina no longer accommodates the necessary stretching for comfortable, pain-free sex, and lubricants and moisturizers don’t address that problem forever. Over time these products won’t provide complete comfort.
LH: What is a woman to do?
BD: It’s a use it or lose it proposition. The number one treatment for vaginal dryness and pain is to have sex - more sex. The more consistently you are engaging in sex, the more likely sex is going to remain comfortable. For example, my patients in their 60’s who are having sex two to three times per week are not experiencing discomfort. For women who are having sex once a week or once a month, it’s just not comfortable.
LH: Many women start to resist having sex during menopause. Why is that?
BD: For menopausal women its the combination of the loss of innate desire combined with discomfort, which makes it really easy to opt out altogether or decrease engagement. We encourage women to stay engaged even in the face of these issues.
LH: Does a psychological barrier also start to develop in response to the discomfort?
BD: Yes. When you do anticipate pain, the natural response is to contract pelvic muscles, so women get a pelvic floor spasm that adds to the discomfort. That’s why it’s important to address these issues early rather than postponing the conversation. The longer you wait to get help more layers of difficulty may be present and make it that much harder to initiate treatment.
LH: In addition to lubricants and moisturizers, what other treatment is available?
BD: One of the areas I will talk to patients about is the value of using a vibrator, dildo, or stretcher device. These devices are effective when the vaginal canal becomes tighter. Also, many women at this stage of life may not have an intimate partner so to keep sex possible in the future these devices are helpful.
LH: What about laser therapy?
BD: The literature has been controversial on using laser therapy to treat the genitourinary symptoms of menopause, including vaginal atrophy and dryness. The lasers have not been approved for this disorder. The FDA stepped in recently on this issue. There is the promise that lasers might be an effective treatment option, but it is a little too early to recommend that be the first line of treatment. The laser data is not where it needs to be, but it is an active investigation. The good news is that I think we will have quality data soon.
LH: What are the barriers to women being sexually well in perimenopause and postmenopause?
BD: I think the most significant barrier we have recognized is that there isn’t a lot of awareness around what happens to women sexually as they age. The majority of women in a recent study did not even think there were treatment options available. This results in a resistance to treatment and women not seeking out treatment. We need to raise the awareness of what women should expect sexually during the aging process. For example, the changes around sexual health is not always commonly discussed with younger women. When I see a perimenopausal woman, I discuss the symptoms she may expect a year from now and even a decade from now. I tell her we have great treatment options and emphasize that the sooner you get those options going, the better it will be. Don’t wait to address it.
Another barrier is that some women think their symptoms are just part of getting older. Since we don’t talk about this topic, some women are left in the dark. Many women don’t even realize there are effective treatments available to address their concerns.
Finally, a lot of women ask their healthcare provider about their symptoms and just don’t have a provider who is willing to help them or is aware of treatment options. We need more providers to be mindful that sexual wellness during midlife and women’s concerns need to be taken seriously and that there are treatment options. Providers who don’t have a lot of experience in this area should refer women to providers who can help them. It should be an inquiry at every woman’s health visit. This is an area of psychological stress for women, and I don’t think the healthcare world devotes enough time to this topic.
LH: What advice can you give menopausal women for talking to their partner about changes in their sex life?
BD: It’s a really tough dynamic. Couples have a hard time finding the language on how to talk about sex and how to address the changes happening to a woman during the menopause transition and beyond. I often tell patients to go home and tell your partner that we had this discussion and that at some point you need to address your sex life differently.
Partners need to recognize that changes are going to happen, and they need to be on board with what it takes to accommodate that. If that requires taking a vibrator into couples’ sex, then that's what you need to do. For a lot of women, it’s hard to start that conversation or know how to start the conversation. Start with the facts and practical advice and then evolve the conversation from there.
LH: This can be a really tense time in a relationship. How can we restart sex in our relationship and overcome the tensions?
BD: This is a complicated scenario. As women, we start to withdraw from our love language because we don’t always want flirtation to end in sex. Your partner becomes frustrated because you don’t want to have sex. Be really careful about how you see that language changing and try to minimize that. Rosemary Basson tried to help us understand this. Our traditional ideas about sex and desire don’t apply to midlife women. It’s not a straight line from flirting to desire to sex. It’s a circle. Women will enter a sexual event neutrally. Set up parameters in your household that feel acceptable and then communicate so that your partner understands the parameters. If you begin the event neutrally without desire you will start to respond, and desire will kick in, and it will be a lovely experience. Don’t wait for desire to start the process. In midlife, the cues need to change to initiate sex. Start recognizing that waiting for innate desire to lead you there is not going to happen. You have to just choose a time and place. When most women choose it, they will feel that it was perfectly lovely and a great connection.
The other thing that becomes more challenging for women is the ability to orgasm. There is a layer of difficulty present if the orgasm expectation is there. Men often see orgasm as the outcome of sex, and if orgasm doesn’t happen, they may feel like they failed in some way and the experience is less satisfying. Women need to explain to their partner that just because they don’t orgasm doesn’t mean they don’t enjoy it. For a lot of women, it helps to alleviate the perceived pressure of performance for their partner to understand that orgasm isn’t essential.
LH: Midlife women are juggling a lot, and sex is not typically a top priority. How can women effectively deal with this issue?
BD: That’s where the concept of an intimate date comes in. Define a time in your week that might be conducive to sex. After you’ve had a chance to unwind and your other tasks are done. It’s counterintuitive to what we think about sex always being spontaneous. At a certain point, it’s better for women and their partners to start planning for sex in a way that meets both their needs.
LH: How can a woman’s partner best support her during menopause?
BD: I think that it’s a combination of a partner understanding the physiological changes that will or has changed the way a woman responds to sex and this innate loss of desire. Women come in and say that their partner doesn’t think they love them anymore because they are not having sex or it’s become infrequent. This isn’t about loving you less or being less committed. Sex just changes over the course of the relationship. If women can be supported, then this period will go more smoothly and be more satisfying for both parties. On my website, a number of questions come from men. That’s really lovely that they are invested in understanding and improving the relationship.
LH: What if a woman is resistant to dealing with this issue?
BD: I will often say to a patient here is the fork in the road. You can be intimate without having intercourse, or we really do need to actively address and treat this so that you can continue having enjoyable intercourse. Most women say they don’t want to give up on sex and we create a treatment plan. Some women try to ignore the problem hoping it will get better but it won’t. And, a few women are simply not interested in treatment options. If you are in a relationship, eliminating sex from the mix may have negative consequences, so a woman needs to consider that when evaluating her options.
LH: How can we mobilize women to be change makers and champion sexual wellness during midlife and menopause?
BD: Historically, women haven’t demanded the attention around this issue. The women ahead of us have been okay with accepting how society views midlife women. We are starting to claim that now and talking about sexual wellness during midlife more. It takes a long time to change attitudes. We are trying to ignite that process with the conversation we are having now. My goals and passion in the work I do are to make sexual wellness mainstream and eliminate the silence around the changes that happen to women during menopause and normalize the many safe and effective treatments that are available.
For more expert answers to your most intimate menopausal questions, or to send us questions of your own, head over to Lisa Health.
Dr. DePree is the Director of Women’s Midlife Services at Holland Hospital in Holland, Michigan, and has practiced as a board-certified gynecologist and women’s health provider for 30 years. She is a certified menopause specialist and in 2013 was named Certified Menopause Practitioner of the Year by the North American Menopause Society for “exceptional contributions” to menopause care. Dr. DePree also founded the groundbreaking website Middlesexmd.com, a site focused on educating women about sexual well-being, particularly during the menopause transition, and offering curated products that support vaginal health and sexual wellness.