Bellingham Alive | January Feature | Menopause and Andropause

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ANDRO PAUSE Written by Anne Godenham and Kristen Boehm


ging is a privilege (after all, what’s the alternative?) but that doesn’t mean it won’t throw some curveballs our way. Changes to our appearance are expected, and to some extent we know our minds and bodies won’t function the same way forever either. But when it comes to menopause, or the lesserknown andropause, there are some changes we’re just not prepared for. Even if you know on some level what’s coming, many people are caught off guard by certain symptoms or their intensity, and few people have a real understanding of how to manage them. That’s why we gathered information, busted some myths, and spoke with physicians who specialize in this life change, to give you the run-down you need— ideally before the hot flashes start.

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What is Menopause? N DIAGNOSTIC TERMS, menopause is a single day.

It’s the point in time one year after someone's last period, signifying the end of reproductive years. Menopause naturally occurs in all people assigned female at birth that live beyond reproductive years. We also use the term to describe the end of female fertility as the ovaries cease to ovulate and to release estrogen and progesterone. Perimenopause: Meaning “around menopause,” also called the “menopausal transition.” A period of time, usually within a decade, before menopause. Often

described as a transitional time where women may experience symptoms in relation to fluctuating hormone levels and declining ovarian function. Postmenopause: Meaning “after menopause,” the period of time after menopause. Most women experience physical and mental changes, largely due to having extremely low estrogen levels. Induced menopause: Menopause caused by medical treatment. Because induced menopause happens all at once, those with induced menopause may experience the symptoms of peri- and postmenopause without the usual gradual onset.

By the Numbers The average age of menopause in America is 51. Perimenopause most often begins between ages 45-55, and usually lasts about seven years. Based on life expectancy, the average postmenopausal period lasts 25-30 years. Levels of estradiol, the most prevalent estrogen during reproductive years, go from 30-400 picograms per milliliter premenopause to 0-30 picograms per milliliter post-menopause.

Treatment Systemic or localized hormone treatment Non-hormonal medication Counseling Lifestyle adjustments 40

Symptoms Vasomotor symptoms • Hot flashes • Sweating • Heart palpitations • Changes in blood pressure Genitourinary syndrome of menopause • Vaginal dryness • Increase in urinary tract infections • Increase in urgency and pain while urinating • Relaxation of the pelvic muscles and incontinence • Decrease in genital sensation Miscellaneous • Mood swings or changes in mental health • Changes in arousal and libido • Joint pain • Changes in hair growth • Changes in weight • Bone loss and an increased risk of osteoporosis • Increased risk of cardiovascular disease

What is Andropause?


OMETIMES CALLED BY the misnomer “male

menopause” or even “manopause,” andropause refers to a group of symptoms linked to an age-related decrease of testosterone levels in people assigned male at birth. Unlike menopause, andropause does not have to do with male fertility. After puberty, people assigned male at birth remain reproductive their whole lives, barring complications.

Andropause is not a guaranteed or universal experience, and many won’t experience low enough testosterone levels to induce symptoms. Medical terms for a decline or deficiency of testosterone later in life are late-onset hypogonadism and age-related low testosterone.

By the Numbers

Symptoms • Low energy • Hot flashes • Issues with sleep • Irritability/mood changes • Joint pain • Changes in hair growth • Changes in weight • Decreased muscle mass • Decreased bone density and a higher risk of osteoporosis • Sexual/erectile dysfunction

Andropause symptoms may begin around someone’s 40s or 50s. Males’ testosterone levels naturally decline about 1% per year after age 40. An estimated 10%-25% of older men have testosterone levels considered to be low.

Treatment Systemic or localized hormone treatment Non-hormonal medication Counseling Lifestyle adjustments January 2024 41

Endocrinology 101 B

EFORE WE GET INTO the nitty gritty of it all,

it’s important to have an understanding of how hormones work in the body. Of the 11 major organ systems that keep us up and running, the endocrine system is the one that deals with hormones. Although people have been aware of some of the effects of hormones since antiquity, it’s actually quite a recent field of study! But more on that later. For now, let’s just focus on what the endocrine system is and what it does for us. Organs and glands all over the body produce hormones, which are chemical messengers that travel through the body, mostly via the blood, and help regulate your body’s functions. The effects are wideranging and varied, dealing with everything from appetite and metabolism (like the hormone insulin) to growth and development, reproduction, sleep (like melatonin), stress and mood, response to illness and injury… you name it, hormones probably have a part in it. Organs and glands in the endocrine system are everywhere: the hypothalamus, pituitary, and pineal gland in your brain; the thyroid, parathyroid, and thymus in the chest; the adrenal gland and pancreas in the torso; and, of course, the ovaries and testes, which produce what are called sex or reproductive hormones. Other parts of the endocrine system produce sex hormones, too, but the ovaries and testes are the powerhouses. Remember, hormones are carried all over the body by the blood, and sex hormones are responsible not only for reproductive processes, but also for things like blood pressure, bone density, cognitive and emotional function, and more. Which makes sense, right? After all, sex hormones like estrogens, androgens, and progestogens are utilized in puberty to cause changes all over the body, including the development of secondary sex characteristics like muscle mass, hair, and fat distribution. Contrary to what you might think, estrogen isn’t strictly a female sex hormone, and androgens like testosterone aren’t strictly male. They all work together in every body to regulate things like your blood, bone density, reproductive form and function, mood, and so on. That being said, estrogen is much higher in people assigned female at birth (AFAB), and testosterone is much higher in people assigned male at birth (AMAB). Testosterone is the most common androgen. It’s associated with things like a deepened voice, more prevalent pigmented body hair, sperm production, red blood cell count, and muscle mass. There are three main forms of estrogen: estradiol, estriol, and estrone. Estradiol is the main estrogen in AFAB folks during reproductive years, is considered the most potent form of estrogen, and peaks and falls with the menstrual cycle. During pregnancy, estriol becomes the primary estrogen, and after birth it takes a backseat to estradiol again. Leading up to menopause, estradiol levels fall. After menopause, estrone, considered the “weakest” form of estrogen, becomes the primary estrogen in the body.


Menopause A Brief History


O YOU CONSIDER menopause to be a taboo

subject? Perhaps rationally you don’t feel like it is— it’s a fact of life, we should be able to talk about it! At the same time, it’s not exactly dinner table conversation in many households. But away from the table, people have been theorizing, researching, and talking about menopause for thousands of years. The historical scholar Aristotle wrote about menopause as early as the 4th century B.C., saying that menses cease in most women around 40 or 50 years of age. This was reaffirmed in the first and second centuries A.D. by other wise men like Pliny the Elder and Soranus of Ephesus. As life expectancy waxed and waned throughout history, not much was learned about menopause specifically, although advanced age was associated with infertility in women. In the 18th century, as life expectancy in Europe was on the rise, it’s thought that women started to turn more to their physicians for help with the symptoms of peri- and postmenopause. France in particular saw an explosion of interest and research in the 18th and early 19th centuries. In 1816 a French physician named Charles-Pierre-Louis de Gardanne coined the phrase “menespausie,” then adopted the name menopause in 1821. By the late 1800s and early 1900s, more effects of hormones throughout the body and hormonal deficiencies in the later stages of life were being investigated. In the 20th century, menopause received a large amount of attention. In the 1920s, the hormone estrogen was isolated and identified. In the 1940s and beyond, more health conditions were linked to menopause or ovarian malfunction, and menopause was considered a disease of estrogen deficiency.

In 1942, Premarin, an estrogen pill created using hormones from the urine of pregnant mares, was marketed for treatment of menopausal hot flashes. In 1966, Robert A. Wilson’s book, “Feminine Forever,” claimed that women could fight off the effects of aging and menopause by taking estrogen in order to remain “feminine forever.” First introduced around the same time, the “Grandmother Hypothesis” postulates that it’s beneficial to humanity for older females to be unable to reproduce— that way, their wisdom and experience can be used to take care of other people’s children and the rest of the clan. Hormone therapy remained popular through the end of the 20th century until a study done by the Women’s Health Initiative (WHI) linked estrogen treatment for menopause with breast cancer. The results gained lots of attention in the early 2000s, but have since been widely criticized. Experts now extol the roundly positive effects of estrogen treatment, so long as the dosages are appropriate and the effects of treatment are monitored.

“What I see now is really Gen. X taking a lead in education, empowerment, living well, feeling well, aging well, and really wanting to be on top of their health,” says Dr. Kelly Casperson, MD, a board-certified urologist and founding member of Pacific Northwest Urology Specialists in Bellingham. “Which [makes this] a really exciting time to be a menopause expert.”

*this graph is an artistic interpretation January 2024 43

Andropause Clearing up the Mystery


F THIS IS YOUR first time hearing about andropause,

you’re not alone! Many people are surprised to learn that there could be hormone-related issues for men later in life, especially since they’re compared analogously to menopause, which can be confusing. After all, andropause isn’t like menopause in many ways. It doesn’t have to do with fertility, isn’t very well studied, and isn’t something every AMAB person will go through. But andropause, or at least concern about testosterone deficiencies, has been known about for quite some time. Much like people had a vague understanding of advanced age meaning the end of the menses in olden times, the effects of testosterone have been noted since throughout history, before we even knew what testosterone was. In the 19th century, research was heating up and experiments were done with things like testicular extracts and transplants. As we mentioned, hormone deficiencies were studied vigorously in the early to middle 1900s, including in males. Testosterone was first isolated and identified by European scientists in 1935, and shortly thereafter was synthesized for use as a treatment. Testosterone is now understood to affect many systems in the body, just like other sex hormones (see pg. 42 for a refresher). That’s part of why older men who are noticing an onset of full-body symptoms like fatigue, hot flashes, changes in mental health, and sexual dysfunction are stopping to wonder, ‘Could this be a hormone thing?’ Because andropause has emerged as a concern more recently, it’s been through quite a number of monikers. One of its oldest names is “the male climacteric,” which also speaks to its long history of being compared to menopause.

The climacteric is an older term for the period of an AFAB person’s life that includes everything from perimenopause to postmenopause. It comes from old philosophies about a person’s life being broken up into vital moments or climactic stages, and here, menopause is considered the climactic end to the reproductive years. Andropause has also been called androgen decline in aging male (ADAM), viropause, irritable male syndrome, androclise, the male menopause, aging male syndrome, late onset hypogonadism, and age-related low testosterone. However, all of these names refer to one concept: an agerelated decline in testosterone in AMAB people, leading to an array of uncomfortable or undesirable symptoms.

How Do I Know? So, if andropause isn’t a universal experience, how do you know if you’re going through it? Many symptoms associated with andropause, like joint pain, hair loss, loss of muscle mass, decreased energy, and heart and bone issues are also just part and parcel of aging, and it can be hard to figure out the cause. Your doctor might first want to speak to you about your medical history and do a physical exam. They’ll check that your muscle mass, hair, and gonadal health is where it’s expected to be for your age. If your doctor is concerned about your testosterone levels, they may progress to checking your hormone levels, your pituitary gland, and various other possible causes. Whether or not low testosterone is, indeed, the cause of your woes, there are many types of treatment available.

*this graph is an artistic interpretation 44

Treatment Hormonal



way to alleviate the symptoms is by replacing the missing hormones. Testosterone replacement therapy (TRT) is systemic, so it affects the whole body. It aims to get your androgen levels back to what would be considered normal for your age. This should alleviate the symptoms of low testosterone over time. TRT comes in many forms to suit the needs of patients. Injections: Testosterone injections can either be shortacting or long-acting. Your doctor will inject you every one or two weeks under the skin or into muscle for short-acting shots, or at more spaced-out intervals into your gluteal muscles for longer-acting ones. Topical applications: Testosterone can also be absorbed transdermally, or through the skin. Patches, gels, and creams are usually applied on a daily basis. Patches can cause skin irritation from the adhesive, so you want to make sure to rotate application sites. When using gels or creams, you want to avoid skin-to-skin contact with others for up to six hours— after all, what gets absorbed through your skin can be absorbed through others’. There are other forms of TRT, like patches and gels for inside the mouth or nose, surgically implanted pellets, or capsules taken orally, but these are associated with more side effects.

Non-hormonal Hormone therapy isn’t right for everyone, and there are many other ways to treat andropause. Other medications: Antidepressants like selective serotonin reuptake inhibitors (SSRIs) or serotonin and norepinephrine reuptake inhibitors (SSNIs) can help with hot flashes and with the mood changes associated with andropause. There are also non-hormonal drugs to treat vasomotor symptoms like hot flashes and night sweats, and phosphodiesterase 5 (PDE5) inhibitors for erectile dysfunction. Counseling or therapy: Having a professional to talk to can help you navigate the irritability, anxiety, or depression sometimes associated with andropause. You may also be going through other changes at this point in your life in regards to your health, career, and family that could be affecting you. Cognitive behavioral therapy or other counseling can help! Lifestyle choices: Your lifestyle choices can make a big difference in your andropause symptoms! Not only will you feel better in general if you introduce more joyful movement and eat what your body needs, you may also be able to naturally increase your testosterone levels. “For men, there is no cliff where the testicals just stop making testosterone, and lifestyle changes really do matter,” says Casperson. “Adequate sleep, muscle-bearing exercise, healthy diet, no drugs or alcohol, and stress reduction. That’s the five-point, naturally-raise-your-testosterone plan.” January 2024 45

Hormone Therapy: I

A Focus on Safety


probably heard of hormone replacement therapy, or HRT, but there’s a lot the average person doesn’t know about hormone therapy. Let’s start with the fact that HRT is actually a misnomer when it comes to menopause in middle-aged women. For most women, who experience menopause in their early- to mid-fifties, the hormonal treatment they’d undergo is called menopausal hormone therapy. This is because the dose is far from a full replacement of the hormone levels we have in our younger bodies. “As we age, our bodies cannot handle those high levels of hormones,” explains Dr. Susan Reed, professor emeritus in obstetrics and gynecology with an adjunct in epidemiology at the University of Washington. “So for example, the hormone doses we use for menopausal hormone therapy, or MHT, are at least 1/4 and often 1/8 to 1/10 the dose of what we would be giving for a birth control pill, for example— a much much lower dose.” It’s only when a woman goes through menopause very early, say at age 30, that the full level of hormones would be replaced and HRT would be the correct term.

Estrogen & Progesterone for Menopause The next thing to understand is which hormones are being supplemented with MHT— for women who still have their uterus, it’s usually a combination of estrogen and progesterone. Progesterone or progestin (a medication similar to progesterone) is needed to balance the effects of estrogen on the uterine lining, to decrease the risk of endometrial cancer. Women who’ve had a hysterectomy, on the other hand, can take estrogen without the progesterone, which dramatically reduces their risk of developing breast cancer as a result of the treatment— it’s the combination of estrogen and progesterone that creates that risk. For vaginal dryness and urinary symptoms, a low dose of localized estrogen can be used, but to treat a broader range of symptoms patients need a higher-dose product delivered through systemic therapy such as a pill, patch, or cream. 46

Dr. Susan Reed

Photo Courtesy of Dr. Susan Reed

MHT has been proven to improve bone density and significantly reduce the symptoms of menopause, but it does carry risks. The most important thing to know is that doses are much lower than you might imagine, which means so are the potential side effects— for most people. “For individuals who have the highest number of symptoms… doses of hormones we’re giving are quite safe for people without risk factors. [So] all of the things that we heard about from [the] WHI [trials in] 2000 to 2004, they don't apply,” Reed notes. “A lot of people’s fear is because of that Women’s Health Initiative study,” agrees Casperson in a separate interview. “Hormones aren’t right for everybody… but by and large, if you look at the prescription medications that people take, these are among the safest medications that are out there.”

Common Menopause Myths The Myth: Menopause won’t happen to me until I feel old, and then there’s no way of knowing when it’ll happen.

The Truth: Menopause can begin at various points in your life, including prematurely, either naturally or due to medical complications, or as late as your 60s. As for knowing when it might happen, while you won’t have a guaranteed date you can make an educated guess based on medical averages and when your mother went through it.

The Myth: I won’t have any symptoms until I’ve officially hit menopause, so if I’m still having periods then whatever I’m dealing with can’t be menopause.

The Truth: Sometimes women will notice their perimenopause symptoms, but don’t realize they’re a part of menopause. In fact, symptoms usually begin before the last period, during what medical professionals call “the menopausal transition”—sometimes this is even when symptoms are most severe.

The Myth: Menopause is linked to the uterus. The Truth: Menopause is actually the result of the ovaries no longer making reproductive hormones. So if a woman has her uterus removed but not her ovaries, she’ll no longer have periods (and will therefore qualify as menopausal) but she won’t experience symptoms as long as her ovaries keep producing hormones. Removal of the ovaries, on the other hand, will trigger symptomatic menopause.

The Myth: Menopause isn’t that bad; you should just grit your teeth and bear it.

The Truth: Even if you can bear the symptoms of menopause (which is genuinely impossible for some people with severe symptoms), why should you? You deserve to get help for medical symptoms of any kind! There’s absolutely no shame in asking your doctor about your treatment options.

The Myth: You can’t have sex (or at least good sex) after menopause.

The Truth: This is absolutely not true— in fact, some women have better sex lives after menopause, often because they’re more in-tune with what their bodies need to feel good and more motivated to communicate with their partners about it. The WHI study pointed to things like increased risk of And while the first three conditions are much less likely to apply to patients without prior risk factors, breast cancer is still a concern for patients under the age of 60. “What does appear to matter is the duration [of hormonal treatment],” Reed says. “Taking menopausal hormone therapy for four to five years, if [... for example you were on] birth control pills right up until the time you started your menopause hormone therapy, then [you have]

The Myth: Hot flashes are the only noticeable symptoms. The Truth: While we’d love to reassure you that you’re the only one who’ll ever know you’re going through it, menopause can be noticeable to others— especially to those who know you and your body well. Symptoms like vaginal dryness, mood changes, and hair loss— and gain, in places you might not expect— may let your partner know that

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Common Myths continued

something’s going on. So even if you think you can hide the hot flashes, you’re better off just talking to them about it.

The Myth: Menopause is the beginning of the end for your body, so there’s no point in continuing to prioritize your health.

The Truth: This is so grim, we know, but some people really believe it! That said, we’re here to tell you that there’s absolutely still value in keeping healthy. If anything, your body needs your attention even more. Regular low-impact exercise like biking or swimming can help stave off osteoporosis and reduce the risk of fractures— plus it’s great for your mental health.

The Myth: Your body’s nutritional needs won’t change much as a result of menopause.

The Truth: Our nutritional needs are, by nature, changeable. They shift according to our levels of movement, our general health, and, yes, our age. When it comes to the menopausal transition, you’ll want to pay particular attention to your calcium intake— postmenopausal women need about 200mg more than they did before menopause. And in order to absorb that calcium, you’ll need to get more Vitamin D as well— but make sure to talk with your doctor about supplements and dosages, because too much of either of these can lead to kidney stones and other side effects.

The Myth: Once you hit menopause, your confidence tanks.

The Truth: Actually, many women feel more confident after menopause. Likely in part because they’ve just had more time to get to know and like themselves, but there’s also something to be said for the freedom that comes with getting older, especially as women in a patriarchal society. It gets easier to let go of people-pleasing and speak up about your own needs and desires as we age out of the ingénue stage.

maybe another five years at most [of MHT]. For people who have not been on hormone therapy, you're probably fine for 10 years, and not increasing your breast cancer risk.” That said, the risk does exist, and it needs to be considered in conjunction with your doctor. Fewer than one in 1000 women per year will develop breast cancer as a result of taking hormones, which is actually lower than the breast cancer risk associated with increased estrogen in larger bodies— to put things into perspective. “Some people will say, ‘Oh, that sounds pretty low, not too bad,’” Reed says, “But we all know people with breast cancer, and you don't want it to be you. And as a prescribing physician, I don't want this for my patients at all.” Before we move on, Reed has one more important point to make about hormonal therapy. Make sure to stick with FDA-approved products and avoid unregulated treatments like pellets or compounding pharmacy products. “FDA-approved products are relatively safe; things like pellets are not safe,” she states firmly. “Pellets are an increased risk for endometrial cancers and breast cancers because of the doses— they just can't be controlled. [...] The FDA regulates that whatever is on the label is what is in that product that you're putting into your body; [pellets and] compounding pharmacies are not regulated by the government in that same way.” The bottom line: Your doctor is the best person to help you decide whether HRT is right for you. As with any medical decision, it’s all about communicating with your doctor and making informed decisions. Your physician will help you weigh the intensity of your symptoms and the likely dosage against your unique risk factors and length of treatment, to come to the right answer for you.

The Myth: Being around men can help delay menopause. The Truth: In 2020, a study published by the Royal Society of Open Science disproved the wive’s tale of male pheromones having an impact on when people go through menopause, but they did find a correlation between being married and later menopause. The two likely causes were less stress due to a higher household income (because it was combined with a partner’s) and sexual activity at least once a week. It turns out that any type of weekly sexual activity has a correlation to delaying the natural onset of menopause, likely because engaging in reproductive/sexual behavior makes the body think that it’s worth preserving the highenergy resources needed for ovulation and periods. 48

“FDA-approved products are relatively safe; things like pellets are not safe,” she states firmly. “Pellets are an increased risk for endometrial cancers and breast cancers because of the doses— they just can't be controlled." — Dr. Susan Reed

Testosterone for Andropause Medical professionals don’t agree about the significance of the drop in testosterone that occurs in men as they age. Unlike menopause, andropause doesn’t carry immediate, identifiable symptoms that set it apart from the natural process of aging. Which is why some doctors don’t recommend testosterone replacement therapy in most cases of male aging— it’s unclear whether it will make enough of a difference to justify the potential side effects. There haven’t been many studies on men with healthy levels of testosterone, so there’s no solid baseline against which to measure either the success or the side effects of TRT. The risks are also less well-known than those of MHT for women, but that doesn’t mean they don’t exist. Males who take testosterone aren’t just adding it to what their body already makes— they’re replacing their natural function. There’s a feedback loop that controls the production of testosterone in the testes. When your body realizes you have more testosterone circulating, your testes will reduce their production and may even shrink in size. For men who use testosterone in the long term, there’s a higher risk of heart attacks, strokes, and other cardiovascular issues— including death from heart disease. In older patients who are already more likely to have heart problems, this is even more of a concern. Some medical professionals are also wary of testosterone therapy’s potential to increase the growth of prostate cancer cells. While evidence isn’t conclusive, many doctors will shy away from prescribing TRT to men with a higher risk of prostate cancer. With andropause and menopause both, marketing can be dangerously misleading. Men may seek testosterone treatment because of advertising urging them to ask their doctors about “possible signs” of low levels— many of those signs include vague symptoms that can be attributed to a range of causes, like fatigue, brain fog, and joint pain. Unsurprisingly, many of these symptoms are also attributable simply to the process of aging. “A lot of people are trying to make money off [...] people with symptoms,” Reed says. She goes on to advise readers, “Be very careful on the internet. Anything that you click on has to say it's an ad or that it's sponsored. [...] I would beware of those.” For men who are experiencing symptoms beyond a general fatigue or aching joints, though, a lab test can be done and, if their testosterone levels are below normal, their doctor may prescribe testosterone therapy in the form of injections, patches, or a topical gel. January 2024 49

Sexual Function After

‘The Change’


Improving Sexual Function: Manage GSM Symptoms

OR BOTH MEN AND WOMEN, the decrease in

reproductive hormones during ‘the change’ can lead to a symptom that’s as common as it is taboo: loss of sexual function. What does that mean? Well, for women in the menopausal transition or postmenopause, it means a decrease in vaginal lubrication, a thinning of vaginal tissues, and reduced libido. For men, the most common and noticeable issue is erectile dysfunction. “Those things are not only changes in hormones, but they're related to aging as well,” Reed points out. “Our nerves don't work as fast or blood supply to various places in our body is not as great. And so it's a complex problem.” That complexity is not helped by the fact that our society sets us up to hide our concerns about our sexual function. Issues like sex drive or performance or ability to orgasm are cloaked in shame and “should,” which only perpetuates them. But there is hope for a great— if different— sex life after menopause or andropause.

“Genitourinary syndrome of menopause, or GSM. Before they named it that, it was called vaginal atrophy … before that, it was called senile vagina. Nobody liked [those terms],” laughs Casperson. “So genitourinary syndrome of menopause is a mouthful, but it really explains all of the changes in the pelvis because of low estrogen.” Not only does low estrogen after menopause cause changes to your pelvis like more frequent urinary tract infections, an overactive and leaky bladder, and more pain while urinating, it also affects sexual function. Vaginal dryness, thinning tissues, and pain with intimacy are all pretty common symptoms. Casperson recommends localized estrogen to treat these symptoms. People who might not be eligible for systemic estrogen may still be prescribed localized estrogen, which is delivered to the vulva and vagina via creams, rings, capsules, or other methods. Some estrogen does still enter the blood, but not as much as with systemic treatments,

GSM Symptoms thinning vaginal tissue

vaginal burning

genital itching

decreased vaginal lubrication

vaginal dryness

light bleeding after sex


and the dosage level is very low. Female genitalia have a big surface area, lots of blood flow, and plenty of mucosal membranes, which absorbs the medication and retains a high amount of it locally. While localized estrogen is highly recommended as it treats the cause of the issues (lack of estrogen) and all symptoms of GSM, vaginal dryness and pain during sex can also be treated with moisturizers, lubricants, a few other drugs, and even the use of vaginal dilators and topical painkillers.

Improving Sexual Function: Train Your Brain One of the best things you can do to improve your sex life during or after a decrease in reproductive hormones is try to reframe how you think about it— after all, the largest sexual organ is the brain! Life is made up of a series of changes and challenges, and attempting to keep anything about our lives static is an exercise in futility. Sex is no different. As we age, our bodies change, and if we can find a way to accept and adjust to those changes there’s no reason we can’t continue to have a fulfilling and satisfying sexual experience. “Sexual intimacy and pleasurable sexual activities can continue into late life,” Reed says. “We just have to adapt and modify based on what's coming at us. The challenge becomes: orgasm occurs because of vascular supply and

nerves, and these are just slower. So orgasms typically become blunted and it takes longer to achieve an orgasm. So different types of sexual activity are important. More gentle foreplay is important.” And that’s not just for women. Reed’s rule of thumb is that 50% of men in their fifties experience some level of difficulty obtaining or maintaining an erection, and that increases proportionally with age— so, 60% of men in their sixties, 70% in their seventies, etc. An increased focus on gentle foreplay, trying new positions, and even introducing vibrators or other sexual devices can not only help women achieve orgasm more reliably but can also take some pressure off male partners to ‘perform’ in the way they’ve become accustomed to performing. “The best thing is to see a professional to help couples understand what is important for their sexuality and their sexual pleasure, to re-set,” Reed says. “It's important to have an understanding between partners— how often do we really want to be doing this, what gives us pleasure— and make sure that you can try to find a match.” She also notes that, for women, certain types of stimulation actually increase with age. Specifically, the clitoris becomes even more important, which means any male partner who doesn’t have an intimate understanding of the clitoris would do well to learn all he can from a knowledgeable clinician or sex therapist.

vaginal discharge

urinary tract infections

frequent urination

discomfort during sex

burning with urination

urgency with urination January 2024 51

Resources K

NOWLEDGE IS POWER, especially when it

comes to your health. Going into a doctor’s appointment with a rough understanding of what you’re experiencing, potential treatment options, and any questions that came up for you during your research will maximize your time with your physician and make things easier for both of you. When researching any medical condition, it’s essential to make sure you’re looking at reputable sources. Hospital websites are a great resource— the Mayo Clinic and Cleveland Clinic have tons of great information— as are large informative sites like Healthline. The most important thing to look out for is whether the source of the information is trying to sell you something; if so, it’s not a good resource. Our experts have recommended the following sources to help you get started:

Online Resources North American Menopause Society The North American Menopause Society (NAMS) is an authoritative resource on all things menopause and aging. A 501(c)(3) organization, NAMS is composed of 2,900 experts in the field of women’s midlife healthcare, including medical, nursing, psychology, sociology, anthropology, nutrition, and epidemiology leaders. Both Dr. Casperson and Dr. Reed recommend NAMS as an excellent source of research-based, science-backed information, including videos.

Kelly Casperson

My Menoplan My Menoplan provides women with accurate, current, science-based information about the many different treatments available for perimenopause and menopause. It’s a great resource for clear, concise, simple-language explanations of your options. Rosy Rosy is a holistic sexual wellness website designed by doctors and psychologists to empower women to take their sexual health and happiness into their own hands. In addition to their website, Rosy has an app to enable subscribers to access their content from their phones.

“You Are Not Broken” Dr. Kelly Casperson, one of our experts, not only has a book titled “You Are Not Broken: Stop ‘Should-ing’ All Over Your Sex Life,” but also a podcast called “You Are Not Broken.” Through both of these, she talks about womens’ and sexual health, her insights on menopause as a urologist, and empowering folks in their bodies. 52

Photo by Radley Muller

Andrea Phillips, ARNP, CNM of Spectrum Reproductive Health & Gender Affirming Care provides reproductive and gynecological care and hormone therapy to a diverse body of patients. She is a Health at Every Size (HAES) provider with training from the North American Menopause Society, among other reputable medical institutions. 200 Old Fairhaven Pkwy., Ste. 202, Bellingham, 360.230.4460,

Dr. Jennifer Scanlon of MauveMD is committed to providing evidence-based care and support to women in midlife, especially during the menopause transition. 119 N. Commercial St., Ste. 310, Bellingham, 360.230.8436,

Photo Courtesy of Spectrum Reproductive Health & Gender Affirming Care

Local Specialists & Clinics

Andrea Phillips

Photo Courtesy of MauveMD

Dr. Emily Sharpe is a Bellingham-based naturopathic physician who specializes in hormone conditions, including both menopause and andropause. 2219 Rimland Dr., Ste. 201, Bellingham, 360.734.1560,

Karen Lee, ARNP, NCMP of Woman to Woman in Mount Vernon offers gynecological and reproductive healthcare for women of all ages, including specialized menopause diagnosis and treatment. 1725 S. 10th St., Mount Vernon, 360.424.2112,

Jennifer Scanlon

Emily Sharpe

Photo Courtesy of Dr. Emily Sharpe, N.D.

Karen Lee

Photo Courtesy of Woman to Woman

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