Sex and menopause: The Sizzle and The Fizzle

The Sizzler's attitude: Open, positive, motivated 

For women who can adjust to life's many changes, menopause is liberating because they are no longer menstruating. They also know that the end of fertility does not mean the end of functional living. Enjoying life, engaging in satisfying activities, making career changes, and pursuing dreams with a passion are common behaviors when keeping a positive outlook.

These women are not afraid to reach out for emotional support when needed. Sometimes they join menopause education and support groups. When the going gets tough, they are not afraid to ask questions about their health and to seek out the services of health care professionals. They are open with their partners and their health care providers, even if it is difficult to talk about sexual concerns. Fundamentally, they look forward to an enjoyable sexual future.

Some women become “over-sizzled” and experience an increase in sexual drive when they reach menopause. Increased libido can make a woman feel helpless because she feels alone. Often, her partner has difficulty keeping up with her, and she has no outlet for her sexual energy. One woman shared her frustrations on the bulletin board at the Prime Plus Red Hot Mamas web site (www.redhotmamas.org):

From reading other postings I really get a sense of the grass is always greener on the other side. What is new for me, 8 years past a hysterectomy and a year from 50, is an increased sex drive. Frustration level to the point I am crying. Problem is I am divorced and do not have a permanent partner… Sometimes I feel like I am a total genetic freak. This is interfering in my finding a partner, hard as that is to believe. But all of the men I have met my age are not able to keep up with me in day-to-day activities let alone with sex. I have a much larger sex drive than I did in my 30s…I feel short-changed in that no one warned me. How many other women are experiencing this?

Increased libido doesn't have to affect an older woman's life negatively. She may feel guilty or ashamed of her sex drive. By transferring that energy into other constructive avenues (yoga and meditation; a hobby or new sport; masturbation), she may find a balance.

The health benefits of sex 

In addition to the sheer pleasure of the sexual act, there are positive health benefits that result. Consider that sex:

Sex also improves stress and mood, strengthens and improves immunity, improves cardiovascular health, lowers cholesterol, increases intimacy within a relationship—and also improves the male's prostate health.

With all of these positives, why should women want to give up one of life's most pleasurable pastimes?

The Fizzler's attitude: Negative, afraid, devalued 

Some women view sex negatively when associating it with menopause. The perception that sex, beauty, and physical attractiveness are associated only with youth can make the transition to menopause more difficult and uncomfortable.

This message posted on our web site is a good example of the disparaging opinions some women correlate with menopause:

I'm a 50-something expatriate woman in Eastern Europe, left to suffer in silence with a husband who is obliquely immune… I could deal with menopause and aging better, I think, anywhere else. In this area, women are a cheap commodity. They cease to have any descriptive value past the age of 35. They lose their jobs to younger prettier

women, and their husbands too… This is a country with literally millions of gorgeous, young, desperately available women with a short shelf life. A woman like me is without any human value here. Sexuality counts for EVERYTHING here, and according to this society, mine has long expired…

I'm not bad looking, well kept-up, nicely dressed, but it doesn't matter. All the menopause treatment in the world doesn't make me a person here. I don't exist…My life is effectively over. With the end of reproduction we cease to have value. We're old ladies. Nobody wants old ladies.

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Feeling the Fizzle: Changes and symptoms of menopause 

Knowing what to expect in the way of menopausal symptoms may help women understand and cope with them.

Changes in menstruation. Alterations in menstrual pattern and flow can be disruptive for some women. They are caught off guard, not knowing when it will occur. This may put stress on a sexual relationship:

I am 48 years old and have been perimenopausal the past year. Now my periods are unpredictable and I never know when I'm going to start or spot. How do I get my sex life back? Is there a way to stop the bleeding long enough to be romantic? This is driving my husband crazy, and I'm none too crazy about it either. Help!

Hot flashes, night sweats, and more. About 80% of women experience hot flashes in the menopausal transition, sometimes preceded by profuse sweating, palpitations, and crawly skin. For most women, hot flashes are bearable. But for some, the episodes are severe and annoying. They always seem to come at the wrong time, and many women feel self-conscious about them, especially when they have one around a man.

One newly married woman told me that she was preparing breakfast one morning when she suddenly had a hot flash and unbuttoned the top button on her blouse to cool herself down. Her husband looked at her and thought she wanted sex. It was totally alien to him that she was having a hot flash. There is, obviously, a difference between a hot flash and a hot flush from sexual arousal. However, men may not know the difference. Personally, I used to wonder why my mother always seemed to be running around in her slip and opening windows. As a postmenopausal woman, I now know why.

Insomnia. Many women have sleep disturbances but do not attribute them to hormonal changes that occur at menopause. They fall asleep easily but awaken at 2 or 3 a.m. and can't fall back to sleep. In the morning, they are fatigued and irritable. When they make their bed, they just feel like crawling right back in. Hot flashes, night sweats, and urinary frequency all can cause a pattern of interrupted sleep. Some women have told me that if they haven't slept well, they would rather take a nap than have sex.

Mood changes, irritability, panic attacks, anxiety. Even emotionally healthy women say that around the time of menopause, they feel quite fragile and out of balance. One woman asked me whether there is a judicial ruling that states menopause can be grounds for justifiable homicide. She felt sleep-deprived and was having a lot of mood swings. Many women also experience periods of forgetfulness:

When you are so confused and don't know which way to go and forget what you just walked into the room for, what causes this? Is it lack of estrogen or progestin or is it too much of either one? I'm through menopause, my gyn says that I shouldn't be having any symptoms and put me on antidepressants… but I still go through all the ups and downs and confusion. Does anyone have any ideas?

Loss of libido. Sexual desire is an intricate mix of mind, body, and intimate relationships. There is great variability in women's sexual responses at menopause. A loss of sexual interest can be caused by a number of factors and may be problematic for some women, but not for others. A decline in desire may depend somewhat on the quality of the relationship, the frequency and quality of sex prior to menopause, and a variety of biological problems (vaginal dryness, stress or depression, certain medications, other factors).2

I keep hearing how great sex is after hysterectomy, but that is not my case. I am 49 and had a full hysterectomy 3 years ago. Since then, my drive is so low and nothing is like it was before. The only way I can achieve orgasm is with a vibrator and it takes so, so long!! My doctor didn't seem concerned. She thought I should be happy that I wasn't hemorrhaging every month… My husband and I have a great relationship and I so want to feel again; however I just don't seem to have the same feelings or sensations that I once had. I feel as though I've lost such a large part of me. I tried testosterone cream but that didn't seem to offer much. Any suggestions, or suggestions for how to choose a new doctor that specializes in this?

Vaginal dryness, painful intercourse, less response to clitoral stimulation. Discomfort or pain during sex is a common problem due to vaginal dryness. Unlike hot flashes, which improve over time, vaginal dryness will only get worse if untreated. Some women don't share their condition with their partners. Instead, they avoid sex. Many women also hesitate to consult with their doctors because they are too embarrassed. They also do not know that there is relief for pain and discomfort.

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The Red Hot Mamas Menopause Management Education Programs are conducted in more than 70 hospitals in 28 states. Approximately 230,000 women are currently attending these programs. The organization's web site (www.redhotmamas.org) provides menopausal health information to patients and providers. It features an Ask the Expert column, a bulletin board, and a monthly e-newsletter. This web site, in teaming up with three other web sites, gets approximately 250,000 visitors per month.

Table 1. FOR WOMEN AND THEIR PARTNERS: MAKE IT THROUGH MENOPAUSE AND KEEP SEX SIZZLING!

	Women	Partners
	• Find the motivation to keep sex satisfying! Use lubricants to help with painful intercourse. If desire is waning, try new and different approaches to keep it alive. Low desire does not have to mean “no sex.” Rekindling desire may seem difficult during menopause, but it is attainable with knowledge, motivation, and support from your partner and physician.	• Be supportive. Know the facts about menopause and understand that the symptoms do not last forever. Stay calm and don't feel you are to blame. Your partner may display emotional and physical symptoms 3 to 10 years before her menstrual cycles cease. These symptoms may continue for several years after her period has stopped.
	• Unravel the mystery of menopause by becoming proactive about your health. Talk to your doctor about your sexual concerns. Become knowledgeable about menopause and the shift in sexuality that may occur in the years before menopause. If you know what to expect, you may be able to deal with it better.	• It is important for you to understand what the process and experience is all about. Learn to recognize the symptoms that may affect your sexual functioning as a couple. She may have hot flashes, night sweats, profuse sweating, insomnia, heart palpitations, fatigue, headaches, vaginal dryness, painful intercourse, and a decline in sexual energy. These symptoms range from moderate to severe and can be very disconcerting.
	• Be prepared to sort through an enormous amount of information to find the quality information you need. Your doctor can help you with this task and inform you of your options. Learn about hormone therapy— estrogen, progesterone, androgens, and what risks they present. Ask about nonhormonal alternatives for keeping your vagina moist (moisturizers, lubricants) and for alleviating hot flashes (selective serotonin re-uptake inhibitors, or SSRIs).	• Weight gain is another common symptom. Encourage your partner to get help from her doctor, to exercise more, and watch her diet. Support her by exercising with her and preparing light meals.
	• Understand that having a high libido at menopause is a normal condition; realizing that it is normal reduces guilt. It is also important to know that sex drive is not gender-driven—men don't always have a stronger sex drive than women.	• Don't take it personally or become resentful if you notice changes in her sexual appetite. She has not lost interest in you, she is having hormonal fluctuations that may be causing some of the problems. Don't just give up on sex or find another partner. This will have a devastating consequence on your relationship.
	• Don't be embarrassed to discuss your changes and communicate your needs with your partner. You'll be surprised to find that the challenges you face at menopause may open up new sexual dimensions. Be patient and kind to yourself. Remember that sex is not an exclusive birthright only for the young. It may need cultivating a little more at menopause, but it should last a lifetime.	• Work together, support one another, and strengthen your relationship. Stay connected, stay calm, validate her concerns, be open to her needs, and romance her. Her emotions are riding a roller coaster. She'll appreciate a phone call from you during the day, a love note, a dinner out. Tell her she looks sexually enticing. Don't be afraid to show your love and concern.

I'm 51 and postmenopausal. My biggest challenge sexually is that I can no longer have intercourse because it's too painful. I am currently using a vaginal cream topically every night and a vaginal tablet twice a week, without any real results. I can still have orgasms, and although my libido is low, I can work at it. Any suggestions?

Urinary tract infections, bladder control difficulty. Many women believe that urological problems only occur in older women. They are unaware of the effects that estrogen has on the bladder as they go through menopause. These changes may include an increase in urinary tract infections (UTIs), urinary urgency, incontinence, and other problems. Women sometimes are too embarrassed to discuss these issues with their doctor. The following posted message is from a husband:

I am 61 and my wife is 64. She gets UTIs about 35% of the time we have sex. When she goes to the doctor she never gets cultured to determine which of the common 5 bacteria she actually has. I got tested and the results were negative. I think the infection has a mechanical cause because of low lubrication levels. We do use KY and I have noticed if things were drying out a little during sex, it seems there is an increased frequency in her UTIs. Anyone have any opinions on KY or a better lube?

Does anyone have experience with female condoms? Do they lessen the frequency of UTIs? I did a lot of online research and found estrogen creams and a vaginal ring that has a low-dose estrogen release. My wife had an estrogen-dependent breast cancer so she can't have any more hormones of any kind.

I gave my wife the summary of my online results. She no longer uses soap to wash the genital depths, drinks 8 oz. cranberry juice every day, and takes a cranberry pill too.

Weight gain. Weight gain is a great concern to many women as they enter the menopause transition. A gain of 5 or 10 pounds may cause anxiety because they do not know what is happening to them physiologically. They are not eating more, they're just putting on more pounds. This may trigger loss of self-esteem .

Other common symptoms include joint aches, headaches, and cognitive difficulties such as memory lapses and fuzzy thinking.

Communication needs vast improvement 

In 2000, Red Hot Mamas commissioned a Harris Interactive Survey of more than 2,200 physicians and menopausal women and their partners. The survey was headed by Philip Sarrel, MD, Professor of Psychiatry and Obstetrics & Gynecology at Yale University School of Medicine, and myself. The survey gauged the level of women's general knowledge about menopause and female sex hormones. Respondents included 158 OB/GYNs, 143 primary care physicians, 580 menopausal women ages 40 to 55, and 1,352 partners of menopausal women.

Women's responses showed a limited understanding of the changes that occur during menopause and how the changes can affect their physical health and well-being, including sexual relationships. They also showed an unsettling lack of understanding regarding the role of hormones and sexual desire during menopause:

In addition, women do not associate their hormonal changes with a loss of libido.

The survey also revealed a serious lack of communication about sexual issues related to menopause. Physicians do not raise the issue because they feel women are not prepared to talk to them. Women do not raise the issue because they don't want to impose on the doctor, or because they haven't had experience with these types of discussions.

But patients and physicians do want to talk: 61% of OB/GYNs and 46% of primary care physicians said they are very comfortable talking to their menopausal patients about sexual problems, and more than 90% of all physicians are at least somewhat comfortable. Among women respondents, 76% are very or somewhat comfortable discussing sexual issues with their physicians, and 56% would most likely talk to the physician if they were experiencing a sexual problem. However, the majority of physicians feel that only some or relatively few of their patients are comfortable talking to them about these issues. See the patient aid on page 75 for ways to encourage more open communication.

Sex should always sizzle 

It is important to emphasize that even with all the changes of menopause, women can and should have active and satisfying sexual relations. Sexual problems are often treatable and should never be dismissed as a natural part of growing older.