Dr. Rebecca Brightman expounds on dryness, pain, and prolapse.
Any regular reader of KCM knows that we have a lot to say about menopause and perimenopause. But from the difficult task of unpuzzling the many treatment options to exploring stories about the variety of positive experiences, we sometimes get lost in the weeds and forget one important factor: Sex. Shifting hormones and body changes can alter the way that women interact with their own sexualities. While some women don’t necessarily feel much of a change, many experience vaginal dryness, pain during intercourse, loss of libido, and the embarrassing issue of incontinence (which is not a condition known for its sexiness). In this live event, Katie talked to Dr. Rebecca Brightman about these issues and how to soothe them through lubrication, medication, physical therapy, and reigniting your diminished libido with intimacy. And if you need a little extra help in this area, we have tips for the best sex toys to use with partners, sex toys for individual use (because your solo sex life is important, too!), our favorite lingerie choices, and some date night foreplay ideas to gradually heat things up.
Katie Couric: After menopause, vaginal dryness is a real problem. Why does it happen?
Dr. B: A lot of women don’t realize that vaginal dryness goes along with being menopausal. While night sweats and hot flashes will get better with time, for most women, vaginal dryness won’t. Why does it occur? We know that estrogen improves blood flow to the urogenital tract. It’s not just the vagina, it’s everything surrounding the vagina. Skin all over our body gets thinner, but there are many estrogen receptors on the skin of the vulva. It’s prone to itching and tearing, and the vaginal wall becomes less stretchy. It loses its elasticity. All of these things can factor into sex becoming more uncomfortable.
What can you do about that?
Women should not be embarrassed to speak to their partners. There are so many lubricants on the market. Some lubricants may be more moisturizing or long-lasting. There are also lubricants targeted toward menopausal women. You want something that’s going to maintain a normal pH in the vagina. If you’re going to use something, there also are vaginal moisturizers that are non-hormonal. Many contain hyaluronic acid, which is a common substance that’s found in beauty products that we put on our faces to maintain facial moisture. Speak with your healthcare provider because there are safe options that contain estrogen.
Estrogen’s received a really bad rap that has since been dispelled, but it does haunt women. It’s important that women understand there are differences between using hormones for hormone replacement versus using some estrogen topically to treat vaginal changes. Also, vaginal changes don’t always occur and aren’t always related to sex. Some people notice vaginal itching and burning. Some women notice more frequent urinary tract infections. Some women are not aware of the fact that menopausal changes do predispose women to have more UTIs.
What about these estrogen options? How are they used?
There are a variety of vaginal estrogen products; historically, there are two types of vaginal creams on the market. One contains conjugated estrogen and the other one’s estradiol. They are inserted with a plunger. There are vaginal suppositories that contain a little coconut oil and estrogen that one inserts on their own. There’s a vaginal ring. The ring is a drug delivery system that provides estrogen to the vagina. Some women also use systemic estrogen vaginally. There’s an oral medicine that can be taken for treating vaginal dryness. There are a bunch of options.
It’s one thing to have painful sex, but a lot of women wrote in saying that they just don’t have a libido and that they feel like something died inside. Is that a normal part of aging?
In general with age, alongside the amount of time someone’s been in a relationship, libido can decline. I think women feel so isolated and they feel that they’re the only ones going through this. My typical response is, “I wish you could be a fly on the wall in my office.” I talk about this all day long. Women have a tough time getting their heads around this. Some of this has to do with the decline of testosterone production. Testosterone is made by both something called the adrenal gland that sits on top of the kidney, but also the ovary. Not by coincidence, testosterone levels peak mid-cycle when women are the most fertile.
When women are not ovulating regularly, that peak in testosterone is no longer there. Many women have low testosterone levels. I will offer supplementation with testosterone. The FDA did not approve a transdermal testosterone patch, so we use teeny tiny doses of male, FDA-approved testosterone products. Sometimes I will use compounded testosterone for my patients. Again, it has to be individualized.
The interesting thing about libido is it’s so multifactorial with women; men are way less complicated. First of all, they make testosterone. Some of the levels drop with age, but they make testosterone. Some men have diminished libido, but women, as we know, tend to complain a little bit more about this. Women are so easily influenced by stress: Life stresses, kid stresses, work stresses. It’s important to tease apart these things. I look at all these factors, but also the biological role, and I make suggestions like sex therapy or stress reduction. Some women are candidates for menopausal hormone therapy, they do feel better and they have an overall, greater sense of well-being. That will drive libido.
Is it true that if you don’t “use it,” you “lose it”?
Any type of sexual stimulation, whether it’s sex with a partner or sex with yourself, improves blood flow to the vagina. During the phases of sexual excitement, the vaginal tissues expand and contract. It’s a healthy thing. Studies have shown that women who remain sexually active have fewer symptoms as they transition through menopause and fewer symptoms of vaginal dryness.
People who are not sexually active and who become sexually active don’t necessarily run into trouble, but some people do. I always like to discuss this with my patients who are about to embark on a new relationship or come to me with concerns of pain. The other thing is that so many women have such avoidance when it comes to sex. That can really play a role in a woman’s desire and also can create great strife in a relationship. I’ve had patients say,
“You know what? Sex is too painful. I don’t want to have sex.” Then their partners won’t even engage in any sexual activity because they don’t want to hurt their partner.
Someone asks, “I am a healthy 63-year-old woman with what I consider a normal sex life with my partner. While he uses Viagra to get in the mood, I’m left to rev up my libido with no help. Is there an equivalent for women who still enjoy sex, but need a little motivation to feel desired and desirable?”
Many men use Viagra to improve erectile dysfunction, but for women, the issue is really desire. Treating desire in women is very different. For some women who have low testosterone, I will give them small doses of testosterone. Sadly enough, the FDA in our country has approved two drugs for treating what we call hypoactive sexual desire disorder. These drugs have been approved for women who are premenopausal, yet my patients who are premenopausal rarely complain about decreased libido.
There’s Addyi, which is taken daily. If there’s no proven efficacy, one should discontinue it after eight weeks. There’s Vyleesi, which is an injectable that gets women in the mood. The major side effect of Vyleesi is nausea. So it’s been a little bit of a hard sell because, if someone’s nauseated, do they really want to have sex?
There aren’t wonderful options for women.
