Psychosexual

Sexual problems

Sexual problems are among the most frequently presented health concerns at menopause clinics. Despite this, one of the areas less often discussed in most cultures is psychosexual problems, such as decreased frequency of sex, a lack of interest in sex, painful intercourse and feeling compelled to have sex. These problems may be associated with physical factors such as oestrogen deficiency, menstrual difficulties, or surgical menopause. Furthermore, psychological and psychosocial factors, such as a negative attitude towards sex and menopause, conflicts between partners, lifestyle factors and culture, can also cause psychosexual problems in menopausal women.

What affects sex at the menopause?

Low Oestrogen

Oestrogen keeps the vaginal tissue moist, lubricated, plump and elastic, allowing for penetration during sex. As oestrogen levels drop at menopause, the vagina and vulval skin can become much thinner and less pliable, thus tearing more easily during sex. More advanced changes can cause tightening of the vaginal entrance and reduction/ fusion of the labia (the outer lips of the vagina).

This can make sex painful, even causing tearing and bleeding during penetration. The skin changes can alter sensation, causing issues with arousal and the ability to orgasm. Is it any wonder that the thought of sex with a sore, dry vagina that might split is somewhat distressing?

The phrase ‘use it or lose it’ is sometimes said, and whilst this may not be overly helpful for a woman struggling with sexual intimacy, reframing this to describe the vicious cycle of loss of lubrication, painful sex, less sex, anxiety around sex and low sex drive may go some way to explaining where this phrase comes from. Regular sex- be that with a partner or through masturbation using sex toys such as vaginal vibrators- may help to prevent some of the more severe symptoms from developing.

Prolapse

Oestrogen helps to keep the pelvic floor tight, and consequently during menopause, symptoms of urogenital prolapse (perhaps present from childbirth) may worsen. Though women can usually physically have sex with a prolapse, the change in anatomy may make sex more uncomfortable. There is often a psychological impact to knowing that vaginal anatomy is somewhat altered if a prolapse is present.

Urinary incontinence

Urinary incontinence is another common symptom around the menopause. This is often due to reduced oestrogen, as many oestrogen receptors exist in the bladder. Issues with pelvic floor (above) can also contribute to incontinence. These symptoms can lead to embarrassment and shame, and women may be afraid to let go during sex due to fear of leaking urine.

Libido

It’s very common to experience low sex drive during menopause. Libido is complex, and many contributing factors drive us to want to have sex. Low oestrogen and testosterone, stress and anxiety, relationship problems, vulvovaginal symptoms and incontinence can all contribute to low libido. Not to mention that feeling physically unwell due to menopausal symptoms likely makes it challenging to handle sexy.

Weight changes

Weight changes around Menopause can negatively impact self-esteem and body positivity, affecting sexual confidence.

Where do I start?

It can be excruciating psychologically to explore the fears and traumas that may be contributing to sexual problems around Menopause, but communication is vital. Talking to a healthcare professional can make chatting about sex feel more normal and help initiate conversations about sex as a couple.

It can be difficult to discuss sex with a partner. How do you bring that into a conversation? We tend to guess what a partner is thinking. Still, the outcome of being honest about feelings around sex is that a partner often feels similar and is open to exploring ways to improve sexual intimacy and experience.

Knowledge of sexual anatomy can be beneficial and will encourage self-exploration- knowing what works for you and being able to show your partner will improve the experience! You may have to re-wire the sexual script in your relationship and explore and experiment – a change in vaginal sensation or structure may mean that what led to arousal and orgasm before doesn’t.

Pelvic floor exercises may improve prolapse symptoms and heighten sexual awareness and pleasure. Many women do not feel confident doing pelvic floor exercises- seeing a pelvic floor physio to assess your pelvic floor and give a structured programme of activities to improve it can be helpful.

Vaginal pessaries can improve symptoms caused by prolapse and are entirely safe to keep during sex.

Look at medications that can affect libido. Unfortunately, many drugs we commonly give for other medical conditions can affect sex drive and arousal.

Vaginal oestrogen, see the section on the genitourinary syndrome of menopause, which will explore treatments to improve changes that may have occurred due to low oestrogen.

Lubrication It is common to feel aroused but still not have adequate lubrication for comfortable sex. A good lubricant can vastly improve sexual experience and reduce discomfort during sex. Many off-the-shelf lubricants contain products that irritate the vagina, so beware and choose carefully!

Some lubricants will have a high concentration of chemicals/ preservatives and a high pH. Both can irritate and predispose to recurrent infections such as bacterial vaginosis and thrush.

Choose a lubricant that has a low osmolality and a pH. Like the natural ph. of the vagina (3.5-4.5), by checking the ingredients if you’re unsure, a Google search can give you more information about what the product contains and which may be irritant.

Avoid lubricants which contain parabens, glycerine, and glycols, all of which can lead to a sore vagina. Be cautious with coloured or flavoured, warming or cooling lubricants also. Flavoured oils can be fun for oral sex, but washing this off before penetrative sex is advisable. Itching and burning sensations from a lubricant are quite a passion killer!

Sylk, YES and SUTIL Luxe are all good sexual lubricants, some available on prescription. Combining oil and water-based lubricants can improve glide during penetration and make sex more comfortable.

Sex toys with silicone dilators inserted into the vagina can improve vaginismus and help gently stretch the vagina over time. Introducing vibration - either with the above for penetration into the vagina- or external stimulation to the clitoris and vulva can improve blood flow and lubrication and increase elasticity, thus reducing pain. Try making this part of a sexual experience with your partner or during self-exploration, as part of masturbation.

Sexual connection and intimacy, a common misconception, is that sex must mean a penis in the vagina, which can be anxiety provoking if penetration is the cause of pain. Sexual connection and intimacy are essential and can be achieved by other sexual experiences. Trying a period where there is an agreement not to have penetrative sex can help remove the fear of pain that may come with the assumption that all sexual contact will end in penetration. This may encourage a couple to relax, explore each other’s bodies and rekindle that sexual intimacy that may have been lost.

HRT and testosterone The suitable HRT can help to improve libido, and testosterone can be added in for hypoactive sexual desire disorder (HSDD) if libido is still not improved by taking oestrogen. Please see the section on HRT and testosterone for more information.

Some women may benefit from a course of psychosexual counselling, mainly if past trauma is a significant contributing factor to sexual difficulties.

The take-home message is to be never afraid to ask- it might just change your sex life!