Sex and Menopause

Sex and Menopause : Do women lose their sexuality after menopause?

Should the words Sex and Menopause still go together?  The good news is that women before, during and after menopause continue to be sexual beings.  However, for anyone who has lived through menopause knows this answer is too simplistic. During menopause, women’s bodies undergo a series of biological changes which have social implications within the context of North American culture along with medical change changes that do influence sexual function. In order to fully acknowledge this complexities of this question, the definition of sex and menopause, including medical treatments aimed at mitigating its less desirable aspects, and the psychosocial implications of menopause, itself, must be explored.

Menopause & Social Implications

Menopause refers to the time when a woman ceases menstruating. Menopause marks the ending of a woman’s reproductive cycle in a manner analogous to the way that puberty marks the beginning of a woman’s reproductive cycle. Beginning around the age of thirty-five, many women begin to experience aberrations in their reproductive cycles, a decline in ovulation, and an increased frequency of menstruation, which lasts for fewer days. These changes are part of the natural aging cycle. However, some women experience none of these changes (20%) until their menstruation ends altogether (Clay, 1981). With age, all women’s ovaries begin to react less efficiently to the Lutineizing Hormone (LH) and Follicle Stimulating Hormone (FSH), which originate in the pituitary gland, eventually leading to the complete cessation of menstruation. Menopause refers to a ‘climacteric’ fifteen-year period, encompassing the “gradual process of ovarian failure which normally precedes and extends beyond the last menses and within which menopause is only an event” (Ritz, 1981).

The process of menopause can be rapid or gradual. Rapid menopause is usually iatrogenic; that is when women may have experienced chemotherapy/radiation related ovarian damage or undergone bilateral oophorectomy (removal of both ovaries), initiating premature menopause (Devprabu & Carpenter, 1997). For women who experience gradual peri-menopause, the exact onset of menstrual discontinuation varies from person to person, often beginning somewhere between age 35-45. The exact beginning date of menopause is typically determined as one year from the date of the woman’s last menstruation.

During the reproductive years, a woman’s ovaries play a crucial role in hormonal balance, in that they are responsible for 90% of overall estrogen production (estrogen synthesis) and approximately 50% of daily testosterone production (Devprabu & Carpenter, 1997). The remaining 10% of estrogen synthesis is produced by the adrenal glands and fat cells, which convert pre-cursors of estrogen into estrogen (Robboy, 1998). Similarly, the remaining production of testosterone is produced by the adrenal glands (Devprabu & Carpenter, 1997). This overall decrease in hormonal production, which stems from changes in the hypothalamus, the neural center of the brain, is responsible for the many of physical changes experienced by peri and post-menopausal women (Robboy, 1998). Menopause is typically confirmed through a blood test that confirms the decline in female hormonal levels.

The above definition of menopause, which talks about the ‘failure’ of the ovaries stemming from the hypothalamus, lends itself to the perception that women’s bodies during and after menopause are in a state of ‘decay’. This may account for the uncertainty many people have regarding the loss of feminine sexuality following menopause. Given this assumption, such questions naturally follow.

If women are in the process of decaying, what is left of a woman’s sexuality? Rest assured, women do not lose their sexuality after menopause. In fact women, like their male counterparts, are sexual beings throughout their lives, with both genders experiencing a decrease in estrogen levels, which has been directly linked with sexual functioning. Like puberty, menopause is a period of transition, and is best understood as a part of normal developmental evolution. Within this framework, the expression of sexuality may change, as all humans, themselves, do with age, but it is not a matter of decay or growth, it simply is.

Historically, the ‘diagnosis’ of menopause has been held responsible for every mood change or unexplained feeling that women experienced throughout the climacteric 15 year period. Menopause, representing a state of decay, often required ‘treatment’ to protect women from their natural biological changes. Such interventions have included medication, verbal therapy, hormonal replacement therapy, or surgery. In fact, in the first half of the 20th century, according to the DSM II, women were thought to suffer from a post-menopausal depression, classified as ‘Involutional Melancholia’. The standard treatment of this “mental disorder” often required hospitalization. The association between hospitalization and menopause led many women to fear that the cessation of menstruation might precipitate lunacy. This “disorder” was eventually recognized as an inappropriate category and was subsequently omitted from the DSM III. However, the myth that menopause causes insanity persists (Weissman, 1979).

In stark contrast to the societal values, which the diagnosis ‘Involutional Melancholia’ represent, menopause in actuality may be a positive occurrence. According to a study cited by NAMS conducted by the Gallup Organization, eight out of ten women viewed menopause as a positive event. This survey, consisted of 750 American women between the ages of 45 and 60, 80 % of whom reported feeling relief at no longer have to deal with the hassles of menstruation, for the first time since menarche. They further reported no longer having to experience monthly cramps, low back pain, rapid hormonal changes, blood-stained clothes, or worry about carrying pads/tampons. Overall, the women viewed aging and menopause as a positive event (NAMS, 1998).

Furthermore, post-menopausal women report that they are able to engage in all forms of sexual pleasuring without harboring a fear of pregnancy, nor do they need to concern themselves with birth control methods or their side effects. For example, the side effects of oral contraceptives, one of the most popular forms of birth control, are weight gain; mood swings; remembering to take the pill at a certain time; and the financial burden. Thus, without the fear of pregnancy, many post-menopausal women find themselves more able to enjoy their sexuality and feel are freer to act impulsively.

Common indications of menopause

Common indications of menopause that women in the United States report and their home remedies

Hot flashes, are sudden, uncontrollable fluctuations of body temperatures, similar to generalized flushes. They often begin with a tingling sensation, which rise to the mid-body, causing reddened skin, dizziness, rapid heartbeat, chills, and sweating. Hot flashes can occur at any time of day and in any location. However, they most often occur during sleep. Hot flashes, on average, last somewhere between 30 seconds to five minutes. This effects 75-80% of per-menopausal women in the United States (Bates, 1981), although the degree of impact varies. Only a small percentage of women report that hot flashes impair normal functioning. However, hot flashes can lead to frequent sleep disturbances, causing exhausting, chills and discomfort, all of which can make women feel less comfortable or embarrassed about their bodies.

Hot flashes occur due to changes in hypothalamus functioning (Bates, 1981). In addition, other mechanisms, not yet recognized, may also be responsible for the irregular dilation and constriction of blood vessels (Chen, 1993). Estrogen may be also play a role in hot flashes because they must be absent when a hot flash occurs. Hot flashes seem to be the body’s way of re-signaling the pituitary gland to respond to the decrease in endogenous estrogen. Interestingly, five years after the onset of menopause, 60% of women continue to experience hot flashes (Greendale & Judd, 1993). Yet, regardless of treatment, (including no treatment) hot flashes in most women eventually disappear.

To reduce discomfort that women may experience as a result of hot flashes, women can do several things. Increased level of exercise accelerates the conversion process of androstenadione from body fat into a type of estrogen, estrone (Robboy, 1998). Secondly, adequate fluids, eating a healthy diet with sufficient calcium (NAMS) Vitamins B and C, and decreasing the intake of spicy foods, hot beverages, tea, and alcohol decreases the stress placed on the adrenal glands, allowing them to function more efficiently. Thirdly, taking cold showers, keeping the room cool, and avoiding tension may lower the frequency of hot flashes.

Mood Swings and Depression tend to be caused by constant fluctuations of hormonal levels and/or mid-life events. In a study which examined mood fluctuations for women who were using the pill, Paige (1971), found that changes in hormonal levels impact mood (Paige, 1971). Concomitantly, between the ages of 40-60, children are often leaving home, which can leave women grappling with role changes, the possibility of marital strife and/or divorce, in addition to other mid-life stresses such as professional changes, retirement, and even the death of a parent. Therefore, regardless of menopausal status, developmental stressors may make women more prone to mood swings and depression. When a woman experiences depression, this, in and of itself, can negatively impact the way in which she relates to both herself and others sexually. Moreover, depression tends to diminish awareness of positive sensations experienced by the depressed person. In order to effectively cope with the mood swings and depression, women should be encouraged to talk openly with others about feelings. In fact, participating in a support group women experiencing similar issues may not only be informative (recommendations of doctors, treatments, experiences…) but also normalizing. Women need to gain access to information and also to connect with others in order to subjectively experience that they are not alone in the mid-life feminine process.

Vaginal Atrophy refers to the shrinking, thinning, drying, and decreased elasticity of the vaginal mucosa caused by prolonged deficiency of estrogen (Masters, Johnson, & Kolodny, 1994). Estrogen is, in part, responsible for the lubrication in the vagina. A decrease in lubrication may cause the vaginal walls to more readily become irritated, tear and/or become infected. One common manner in which women deal with these changes is to ignore the pain, while continuing to engage in the very sexual behaviors which lead to discomfort. Over time, this strategy may lead women to associate pain with penile-vaginal intercourse and thus become avoidant of these behaviors. This avoidance behavior may result in either the woman viewing herself as asexual or in others viewing her this way. In reality, the change in female lubrication is more indicative that her sexual partner may need to adjust. She may benefit from prolonged stimulation and/or the use of lubrication. In this regard, there are several options. Women may want to use an estrogen replacement cream, which helps women to self-lubricate. Second, women may purchase over-the-counter lubrications, such as Astroglide or K-Y Jelly or Replens, a nonprescription, non-hormonal lubricant that worked as well as estrogen cream in a 1994 study (Dranov, 1997).

Lastly, according to Masters and Johnson, (1994) one of the best ways to increase lubrication is by engagement in frequent sexual pleasuring. Moreover, because lack of sexual activity may actually contribute to vaginal atrophy, it is important to keep all the pelvic and perioneal muscle groups in active use. In addition to engaging in sexual pleasuring, women may benefit from strengthening her PC muscle which plays an important role in orgasm. This can be done through the use Kegel exercises.

Menopause emotionally or physically disables only a small percentage of the female population (10-15%). Similarly, 10-15% of all women exhibit no symptomology at all. However, most women experience mild symptoms due to fluctuations in hormonal levels (Robboy, 1998). Of these, only a small percentage affected seek medical treatment (Greendale & Judd, 1993). Prior to discussing medical interventions used to reduce discomfort caused by the onset of menopause, there is a fundamental question that must be addressed: Do hormonal treatments improve the quality of women’s lives? And, if so, to what extent? The issue of whether women should be advised to embark upon long term hormonal treatment is controversial. Medical arguments rely heavily upon the interpretation of research ‘results’. The interpretation of these ‘results’ are subjective not only because of how scientific information is understood, but also because of concepts related to what constitutes ‘disease’ versus the ‘natural’ aging process.

Hormone replacement therapy seems to indicate that if declining hormones are replaced than she will resume her “natural state”. Thus, the question emerges, even if women are able to live longer, reproduce, and decrease certain medical risks, won’t old age naturally increase other risks? Furthermore, if a woman embarks upon one of these forms of medical treatment, are the benefits worth the financial burdens and restraints engendered by depending upon medical supervision? Perhaps the low compliance rate (approximately 50%) speaks directly to this issue.

Estrogen Replacement Therapy (ERT)

Estrogen replacement therapy made it’s debut in the 1940s as a treatment to reduce the negative impacts of menopause. By 1992, doctors had prescribed ERT to 36.4 million women (Wysowski, Golden, & Burke, 1995). Part of the rise in popularity of ERT as a form of treatment to cure vaginal dryness, cancer, heart trouble, and depression followed a huge advertising campaign in the 1970s to increase the popularity of the drug Premarin ® (Seaman & Seaman, 1991). However, the numbers of women using ERT may be misleading. According to Ravikar, an observational study found that 20-30% of women who are prescribed ERT opt not to fill their prescriptions.

Furthermore, within 9 months of use, an additional 20% stop using this form of treatment. Therefore, there is a 40-50% non – compliance rate (Ravnikar, 1987). Issues of non-compliance have improved due to the invention of transdermal E sub 2, which is an estrogen, in the form of a patch that is placed on a woman’s arm. However, this patch must be replaced daily, which is problematic in terms of compliance issues. In order address this, attempts are being made to design a patch that needs replacement once a week. The patch currently used specifically relieves menopausal symptoms, decreases vaginal atrophy, and forestalls osteoporosis (Jewelewicz, 1997).

ERT is often recommended to menopausal women as a way to prevent the ‘decay’ of women. ERT has been found to decrease the rate of heart disease, slow the rate of osteoporosis, and improve cognition and slow its age-related decline . In 1991, a longitudinal study was conducted which tracked the rate of women taking ERT and the rate of heart disease over ten years. It was found that ERT was associated with a reduced rate of heart disease. However, the results may be problematic due to the design of the study. Not only were the groups of women who participated in the study not matched, but the study was designed 10 years after the use of the ERT (Stampher et al, 1991).

ERT may be important to slowing the rate of osteoporosis development because estrogen is an important factor in bone growth. According to Lobo, ERT also improves cognition (Lobo, 1995). To determine the effects of ERT on the cognitive capacities of postmenopausal women, 70 women who used estrogen were compared with 140 women who had never used estrogen to see who would perform better on cognition tests. The results of this study demonstrated an association between ERT and improved cognition (Schmidt et al., 1996).

Drawbacks to ERT may be dose and duration dependent (Holst, 1983). The known side effects of ERT consist of an increased risk of endometrial and breast cancers and similar rates of osteoporosis for males and females beyond age 80 [Boston Collaborative Drug Surveillance Program, 1974 #20. ERT masks the natural evolution of the body therefore, decreasing the natural transitions. Furthermore, with the invention of ERT, women, more so than ever, must rely upon chemicals for their health. The long-term implication for such women is that they must always be under the care of a physician which requires not only frequent monitoring, but is expensive. For women concerned about post-menopausal sexual functioning, ERT may be a subject worthy of exploration. As mentioned earlier, ERT directly improves vaginal lubrication and does not interfere with the newly found freedoms from menstruation and fear of pregnancy associated with menopause. However, while ERT may ‘cure’ some of the problems associated with menopause, ERT’s side effects, such as cancer of the uterus, may outweigh the benefits. Therefore, it is recommended that women avail themselves of this form of medication for as short of a time span as possible.

Hormonal Replacement Therapy (HRT)

Hormonal Replacement Therapy (HRT) reduces the risk of cancer of the uterus, because of the combination of progesterone and estrogen (Grady, Gebretsadik, Kerlikowske, Ernster, & Petitti, 1995). As in the natural menstrual cycle, progesterone acts as a stimulant to the growth of endometrium, which leads to its eventual removal, or sloughing off during menses. With ERT, there is no progesterone to counterbalance the effects of estrogen, which chronically stimulates the endometrium which has no way of sloughing off, thus leading to endometrial cancer. This imbalance is mitigated with the inclusion of progesterone in HRT. Since ERT’s debut in the 1940s, research has focused on how to make the treatment safer. Whereas, in the 1940s, estrogens were given to women at a much higher level, 1.25 milligrams, by the 1980’s, the levels were reduced to 0.6 milligrams, with researchers now testing the degree of effectiveness at 0.3miligrams (Robboy, 1998).

HRT is primarily recommended to slow the rate of osteoporosis (Felson, 1993), heart disease (Sullivan et al.,1990), and to decrease frequency of hot flashes and night sweats (Branswell, 1998). In one study, it was found that after 15 years use of HRT, the death rate of women was decreased by 40% (Henderson, Paganini-Hill, & Ross, 1991). HRT is known to prolong the life of post-menopausal women primarily because of a reduction in cardiovascular disease, specifically coronary heart disease (Lobo, 1995). In addition, HRT is often recommended to women who experience surgical menopause due to a hysterectomy / oophorectomy for non-cancerous conditions (Langenber, Kjerulff, & Stolley, 1997). HRT has benefits over ERT, the addition of progesterone to the last ten days of the cycle, eliminates the increase risk of breast cancer (Martin & Freedman, 1993) from the increased usage of estrogen (Colditz et al, 1990). While both HRT & ERT decreases certain health risks, they increase others. However, on average, women tend to have more complaints about the side effects of HRT. This includes “spotting” several days each month, which can be a source of frustration for women (Dranov, 1997) and engorged breasts which can be very painful (Robboy, 1998).

The estrogen within HRT, like ERT, acts to increase vaginal lubrication, strengthen bones, and decrease blood pressure. Some people even believe that HRT may increase a woman’s sexual desire. One of the primary advantages (and disadvantages, depending) of using both estrogen and progesterone is that it stimulates ovulation. This means that women can prolong the reproductive cycle and, with the use of medical technology, (oocyte donation or frozen eggs) continue to bear children . In fact, it has been reported that a 63-year old woman was able to conceive and bring a healthy child to term. To date, there have been at least 100 children born to postmenopausal women through oocyte donation (Eisenberg & Schenker, 1997).

The idea of birthing children beyond the restrictions of the natural reproductive cycle, alters previous notions of ‘menopause’. Menopause is no longer a determinant of the stop-point for the reproductive life-cycle. This raises a number of ethical issues. Should a woman at any age be encouraged or even allowed to reproduce? What does this mean in terms of a woman’s right to control her own body? The basis of oocyte donation is a fundamental right in the United States, based in part on who has the financial resources to afford it. Is this the same for women who opt to use HRT as a treatment modality? Does society have a greater social obligation to pre-menopausal women trying to conceive than to post-menopausal women? What level of medical technology is considered appropriate? Have these questions evolved from the debate that currently rages around abortion? What are the biomedical-ethical implications? What are the rights of the child? Mother? Father? What are the social implications to the community at large? What are the political issues motivating the rhetoric?

Conclusion to Sex & Menopause

All this seems to indicate that menopause, with the use of new medical technology may have little to no impact on women’s long term sexual and reproductive functioning. Over the years, menopausal women have been viewed as going ‘crazy’ and needing hospitalization, to full functioning women with successful careers, active sexual lives, to having the post-menopausal capability of birthing children. Only politics and medical technology have changed.

Therefore, for women who are trying to navigate menopause the best recommendation is to educate themselves about their bodies. This means reading books and literature, speaking with friends and family, joining support groups either face-to-face or through the web, and conferring in an informed manner with primary care health providers. Make sure that your health care does not have a bias towards one particular drug, and is not afraid to exhaust all the least invasive methods first. Above all, share women should share concerns with their partners. Women, like men, are sexual beings throughout their lives. The most important aspect is self-education and communication with one another.