20 minute read
How to talk to women about sex at menopause
Approaching problems with sexual function within a biopsychosocial framework places the individual at the centre of solutions.
Menopause describes a biological event in a woman’s reproductive life: but it is much more than that. It has social, cultural and relational significance as well. The Diagnostic and Statistical Manual of Disorders (DSM) 5 (DSM-5) and the World Health Organization’s International Classification of Diseases 11 (ICD-11) attempt to classify female sexual dysfunction, but with a firm focus on their biological causes. As a GP and clinical sexologist, however, I know that most of us working in women’s health are only too aware that the problems experienced by a menopausal woman will have unique impacts that will differ significantly according to her particular life circumstances.
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Problems of libido loss, vulvovaginal pain, and changes in arousal and climax are common at menopause, and often there is a lot we can do to help tackle these. Ensuring we approach such problems within a biopsychosocial framework ensures we let women know they are being heard and seen as an individual, and that we place them at the centre of any approach to offer a solution.
There are common themes in each of these areas that may affect women at menopause:
WORDS BY DR ANGELA WRIGHT
BIOLOGICAL
Physical changes throughout the brain and body, due to both ageing and falling hormone levels, can have a myriad of potential effects on women’s sexual function. Oestrogen and testosterone are important in both the central and the peripheral systems that govern our libido, arousal and climax. Reduced blood flow to the breasts and our pelvic organs after menopause contributes to changes in how we experience touch, and also in the ability of the clitoris to engorge in response to tactile stimulus. The ability of our sensory nerves to respond to touch is also reduced as we age – meaning that we may require more intense touch to elicit the same responses we enjoyed at an earlier age.
Loss of oestrogen in the genitourinary tract can also lead to genitourinary syndrome of menopause (GSM). This significantly thins the vaginal epithelium, and can cause changes in lubrication in response to sexual stimulus, and in the ability of the vagina to increase in size in readiness for penetration. It changes the vaginal pH and reduces our defences against infection. Dermatological conditions, such as lichen sclerosus, become more common again in older, oestrogen deprived women. The dryness and itch associated with GSM can contribute to superficial sexual pain, and embarrassment about the appearance of the vulva. This is also true regarding the increased prevalence of pelvic organ prolapse. Bladder issues such as LUTS or interstitial cystitis may also become worse after menopause, and impact enormously on sex, making women anxious about pain or loss of control of continence during sex. We may have to ask direct questions to elicit concerns about these things, as women might feel a great deal of embarrassment about raising them.
In addition to the more direct effects on sexual function of post-menopausal hormone deprivation, there are also wider effects from the loss of the relative oestrogenic protection against other conditions such as cardiovascular disease. The increased prevalence of comorbid conditions, and the side effects of the medicines we prescribe to treat them, also have a significant effect on sexual function.
It is important to recognise how individual the psychological impact of menopause is. Many previously healthy women will go through menopause without experiencing any significant psychological distress as a result of it. In fact, many might enjoy freedom from contraception worries, or the time constraints of caring for a young family. Others will have had their family later and be managing the demands of a young child as they try to simultaneously grapple with their menopause. For women who have struggled with infertility, it may mark the final, painful closing of that door. Certainly, we know that for women with premature ovarian insufficiency and surgical menopause, the psychological impacts of their last period can be far greater. What is important to recognise is that no one woman will have the same concerns as another. We need to show that we are sensitive to the issue full stop, and ask the woman sitting before us about how she is feeling, and about what else might be happening in her life.
We increasingly understand, however, that some women are more susceptible than others to the impact of fluctuating hormones on their psychological wellbeing. We also know that sleep disturbances, such as insomnia, are prevalent around menopause and that these also impact on energy levels and mood. What is important is that we explore with each woman in front of us whether their mood is an issue for them at this time – and then consider if it might be impacting the sexual problem they are experiencing.
Being able to enjoy sex, and experience arousal and climax often means being able to switch our minds off from other worries to focus more fully on our sensory experience. Even when everyday stresses don’t manifest as clinical depression or anxiety, the other demands of life at menopause can create a very challenging background to place sexual problems into context with. Where this does form a clinical diagnosis of its own, there are the additional complications of loss of libido as part of these conditions, and the prevalent sexual side effects of the SSRIs and other drugs that we use to treat them.
PSYCHOLOGICAL SOCIAL
Without necessarily realising it, we all carry our own ‘sexual scripts’ with us. These are the received messages – from parents, teachers, books, TV – and our early lived experiences – that underpin our beliefs about sex and sexuality. They help to form our sense of how our own sexuality fits into these societal, religious and cultural norms. For example, do we think monogamy is normal, achievable, desirable? What about our ideas around what constitutes ‘normal’ gender expression, or how we feel about our sexual orientation and those of others? What are normal ‘turn-ons’ and what do we consider ‘kink’? Our beliefs about all of these things will impact how satisfied we are with our own sexual behaviours. They will impact, as other scripts do in all arenas of health, on whether we believe we have a problem that needs solving.
Women’s individual beliefs about the significance of menopause are bound, therefore, to impact on their sexual function. There are many societal and cultural messages around ageing and sexuality that can feel negative to women as they go through menopause. It is important to consider how they feel about the importance of their sexuality as they get older. Whether they feel more, or less attractive as they age? Do they still find their current partner attractive, and feel desire for them? Do they worry about still being desirable to their partner? The women we see are increasingly in second or third long term partnerships too – or dating again after divorce. We also need to recognise the prevalence of non-heteronormative relationships too. All these factors will impact what women perceive to be acceptable, or problematic, in their sex lives.
What can we do to help?
When it comes to exploring the causes and potential solutions to sexual problems, taking time to put them into context is everything. Always ask - is this problem new, or long standing? Does the same thing happen in solo sex, or only when you’re with a partner? Has it happened with every partner? And so on.
It is also worth being aware that research shows that a woman’s sexual satisfaction scores at menopause are more closely linked to the health of her partner than they are to her own health. This should remind us that any woman coming to us for help with her sex life will also potentially be bringing with her the problems of her partner, too. We need always to place the problem in context.
A helpful model to use with your patient is one based on Basson’s Dual Control model of sexual arousal. This essentially reminds us that there is a balance between factors that dampen or inhibit our sexual response, and the factors that can enhance and accelerate it. Working with your patient to identify these sexual ‘brakes’ and ‘accelerators’, using the biopsychosocial model, can help to frame both the problem and the solution in a way that’s pragmatic and clear.
Common areas to consider when doing this are as follows:
NON-EXHAUSTIVE LIST OF MEDICATIONS THAT IMPACT SEXUAL RESPONSE: • Anti-anxiety • Chemotherapy including drugs benzodiazepines • Nsaids • Antidepressants • Opiates • Anti-epileptics • Contraceptives • Antihistamines • Anti-Parkinsonian • Anti-hypertensives drugs • Anti-psychotics
MAKING TIME & SPACE
• Emphasise the need to ensure privacy and energy for sex. • Managing stress and anxiety where they are impacting on libido or arousal, using psychological therapies, breathing exercises, and also mindfulness techniques. • Focus on normalising any body image issues that may exist as bodies age and change. • Explain and psychoeducate: knowing what is 'normal' in terms of our anatomy and sexual function at this life stage can relieve a lot of shame and anxiety.
RELATIONSHIP ISSUES
• Loss of desire in a long term relationship is not uncommon: couples therapy – with
Relate or a COSRT approved therapist – can be hugely enlightening and helpful.
THE ROLE OF HRT, TESTOSTERONE & OTHER MEDICATIONS
• Discuss the role of systemic and local HRT with your patients, and remain conscious that some of the non-hormonal alternatives to HRT may actually hinder sexual response – in some circumstances, alternative approaches such as CBT for menopause may be more useful for these women. • Local oestrogen is often safe for women who cannot have systemic HRT. • Look for obvious culprits in any other medications that might also be affecting their sexual function. • Optimising general health and mobility is likely to optimise sexual function too: in particular addressing bladder issues and pelvic organ prolapse. Gynae physios are experts in helping with pelvic floor tone issues too – referral here can be very useful.
INCREASING AROUSAL
• Explaining that good pelvic blood flow is vital to ongoing sexual satisfaction helps us to encourage women to understand that getting aroused on a regular basis is good for their ongoing sexual function. • Explain to women that sensory changes as we age can make tissues less sensitive, normalising the need for more intense touch. • Toys such as clitoral suckers (modelled on the Eros device) and vibrators can intensify sensation. • Discuss ways to increase eroticism with their partner in order to help them to keep feeling aroused and interested as they age.
Referrals for psychosexual counselling, where possible, can really help couples and individuals with this. • PDE5-inhibitors such as Viagra are sometimes used off licence in women with arousal/climax problems with some success. Tibolone, and testosterone gel, can be useful adjuncts to help with libido and response at this stage. The
British Menopause society has a helpful consensus statement on the use of testosterone in menopause, and there is good evidence that its use can improve sexual satisfaction scores.
LUBRICANTS & MOISTURISERS
• The use of vaginal moisturisers and lubricants, where needed, is important. • Many psychosexual practitioners suggest women try ‘double glide’ when needed – the combined use of an oil and a water-based lubricant – in order to maintain the lubrication successfully for longer during sex.
Despite what we may think, the onset of menopause does not mean it is all doom and gloom ahead sexually speaking. Our role as women’s health practitioners is to both start, and open up the conversation around sex. We need to let the patient decide how important their sexuality is to them – and to be curious about the problem to show them we take it seriously, too. We are able to do far more than many of us realise using our existing skills without needing to spend hours training, or providing psychosexual input. With a few considered interventions, we can make a lot of difference in women’s lives.
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HRT for estrogen deficiency symptoms HRT for estrogen deficiency symptoms in post-menopausal women more than in post-menopausal women more than 6 months post-menopause.2 6 months post-menopause.2 AVAILABLE. AFFORDABLE. EVOREL. AVAILABLE. AFFORDABLE. EVOREL.
Abbreviated Prescribing Information: Acute liver disease, or a history of liver disease if liver function tests have failed to number of exposed pregnancies indicate adverse effects of norethisterone on Abbreviated Prescribing Information: EVOREL® Conti (estradiol hemihydrate/norethisterone acetate) Presentation: Evorel Conti 3.2 mg of estradiol hemihydrate, 11.2 mg of norethisterone acetate transdermal patch. Indication: HRT for oestrogen deficiency symptoms in post-menopausal women more than 6 months postmenopause (or 18 months since last period). Prevention of osteoporosis in postmenopausal women at high risk of future fractures who are intolerant of, or contraindicated for, other medicinal products approved for the prevention of osteoporosis. Dosage & administration: Adults: Evorel Conti is a continuous combined HRT preparation. Patches are applied to the skin twice weekly. One Evorel Conti patch should be worn at all times, without interruptions. For initiation and continuation of treatment of menopausal symptoms, the lowest effective dose for the shortest duration should be used. Guidance on how to start therapy: Post-menopausal women currently not on HRT may start Evorel Conti at any time. Switching from other HRT: Women on a continuous combined regimen wishing to switch from another oestrogen to Evorel Conti may do so at any time. Women on a cyclic or continuous sequential regimen wishing to switch from a sequential combined HRT preparation to Evorel Conti may do so at the end of a cycle of the current therapy or after a 7-day hormone free interval. Unless there is a previous diagnosis of endometriosis, it is not recommended to add a progestogen in hysterectomised women. Method of Administration: The sachet containing one Evorel Conti patch should be opened and one part of the protective foil removed at the S-shaped incision. The patch should be applied to clean, dry, healthy, intact skin as soon as it is removed from the sachet. The patient should avoid contact between fingers and the adhesive part of the patch during application. Each application should be made to a different area of the skin, on the trunk below the waist. The patch should not be applied on or near the breasts, the usual day of changing Evorel Conti patches should be maintained. Children: Not indicated in children. Elderly: Data are insufficient in the elderly (>65 years old). Route of administration: Transdermal use. Contraindications: Known, past or suspected breast cancer. Known or suspected oestrogendependent malignant tumours or pre-malignant tumours. Undiagnosed genital EVOREL® Conti (estradiol hemihydrate/norethisterone acetate) Presentation: Evorel Conti 3.2 mg of estradiol hemihydrate, 11.2 mg of norethisterone acetate transdermal patch. Indication: HRT for oestrogen deficiency symptoms in post-menopausal women more than 6 months postmenopause (or 18 months since last period). Prevention of osteoporosis in postmenopausal women at high risk of future fractures who are intolerant of, or contraindicated for, other medicinal products approved for the prevention of osteoporosis. Dosage & administration: Adults: Evorel Conti is a continuous combined HRT preparation. Patches are applied to the skin twice weekly. One Evorel Conti patch should be worn at all times, without interruptions. For initiation and continuation of treatment of menopausal symptoms, the lowest effective dose for the shortest duration should be used. Guidance on how to start therapy: Post-menopausal women currently not on HRT may start Evorel Conti at any time. Switching from other HRT: Women on a continuous combined regimen wishing to switch from another oestrogen to Evorel Conti may do so at any time. Women on a cyclic or continuous sequential regimen wishing to switch from a sequential combined HRT preparation to Evorel Conti may do so at the end of a cycle of the current therapy or after a 7-day hormone free interval. Unless there is a previous diagnosis of endometriosis, it is not recommended to add a progestogen in hysterectomised women. Method of Administration: The sachet containing one Evorel Conti patch should be opened and one part of the protective foil removed at the S-shaped incision. The patch should be applied to clean, dry, healthy, intact skin as soon as it is removed from the sachet. The patient should avoid contact between fingers and the adhesive part of the patch during application. Each application should be made to a different area of the skin, on the trunk below the waist. The patch should not be applied on or near the breasts, the usual day of changing Evorel Conti patches should be maintained. Children: Not indicated in children. Elderly: Data are insufficient in the elderly (>65 years old). Route of administration: Transdermal use. Contraindications: Known, past or suspected breast cancer. Known or suspected oestrogendependent malignant tumours or pre-malignant tumours. Undiagnosed genital bleeding. Previous idiopathic or current VTE. Active or recent past ATE disease. Acute liver disease, or a history of liver disease if liver function tests have failed to return to normal. Known thrombophilic conditions. Known hypersensitivity to the active substances or to any of the excipients. Porphyria. Special warnings and precautions for use: Before initiating or re-instituting HRT, a complete personal and family medical history should be taken. Conditions which need supervision: If any of the following conditions are present, occurred previously, have been aggravated during pregnancy or previous hormone treatment, supervise patient closely. Conditions may recur or be aggravated during treatment, in particular: Leiomyoma or endometriosis, a history of, or risk factors for, thrombo-embolic disorders or oestrogen dependent tumours, hypertension, liver disorders, diabetes mellitus, cholelithiasis, migraine or (severe) headache, systemic lupus erythematosus, history of endometrial hyperplasia, epilepsy, asthma, otosclerosis and mastopathy. Conditions which require monitoring while on oestrogen therapy: Oestrogens may cause fluid retention. Cardiac or renal dysfunction should be carefully observed. Disturbances or mild impairment of liver function. History of cholestatic jaundice. Pre-existing hypertriglyceridaemia. Rare cases of large increases of plasma triglycerides leading to pancreatitis have been reported with oestrogen therapy in this condition. Therapy should be discontinued if a contraindication is discovered and in the following situations: jaundice/deterioration in liver function, significant increase in blood pressure, new onset of migraine-type headache, pregnancy. Interactions: The metabolism of oestrogens and progestogens may be increased by concomitant use of substances known to induce drug-metabolising enzymes, specifically cytochrome P450 enzymes, such as anticonvulsants, anti-infectives and bosentan. Ritonavir, telaprevir, nelfinavir and herbal preparations containing St. John’s Wort may induce the metabolism of oestrogens and progestogens. Clinically, an increased metabolism of oestrogens and progestogens may lead to decreased effect and changes in the uterine bleeding profile. Oestrogencontaining oral contraceptives have been shown to significantly decrease plasma concentrations of lamotrigine when co administered due to induction of lamotrigine glucuronidation. This may reduce seizure control. Therefore, dose adjustment of lamotrigine may be necessary. Fertility, Pregnancy and lactation: return to normal. Known thrombophilic conditions. Known hypersensitivity to the active substances or to any of the excipients. Porphyria. Special warnings and precautions for use: Before initiating or re-instituting HRT, a complete personal and family medical history should be taken. Conditions which need supervision: If any of the following conditions are present, occurred previously, have been aggravated during pregnancy or previous hormone treatment, supervise patient closely. Conditions may recur or be aggravated during treatment, in particular: Leiomyoma or endometriosis, a history of, or risk factors for, thrombo-embolic disorders or oestrogen dependent tumours, hypertension, liver disorders, diabetes mellitus, cholelithiasis, migraine or (severe) headache, systemic lupus erythematosus, history of endometrial hyperplasia, epilepsy, asthma, otosclerosis and mastopathy. Conditions which require monitoring while on oestrogen therapy: Oestrogens may cause fluid retention. Cardiac or renal dysfunction should be carefully observed. Disturbances or mild impairment of liver function. History of cholestatic jaundice. Pre-existing hypertriglyceridaemia. Rare cases of large increases of plasma triglycerides leading to pancreatitis have been reported with oestrogen therapy in this condition. Therapy should be discontinued if a contraindication is discovered and in the following situations: jaundice/deterioration in liver function, significant increase in blood pressure, new onset of migraine-type headache, pregnancy. Interactions: The metabolism of oestrogens and progestogens may be increased by concomitant use of substances known to induce drug-metabolising enzymes, specifically cytochrome P450 enzymes, such as anticonvulsants, anti-infectives and bosentan. Ritonavir, telaprevir, nelfinavir and herbal preparations containing St. John’s Wort may induce the metabolism of oestrogens and progestogens. Clinically, an increased metabolism of oestrogens and progestogens may lead to decreased effect and changes in the uterine bleeding profile. Oestrogencontaining oral contraceptives have been shown to significantly decrease plasma concentrations of lamotrigine when co administered due to induction of lamotrigine glucuronidation. This may reduce seizure control. Therefore, dose adjustment of lamotrigine may be necessary. Fertility, Pregnancy and lactation: Not indicated, treatment should be withdrawn immediately. Data on a limited number of exposed pregnancies indicate adverse effects of norethisterone on the foetus. At doses higher than normally used in oral contraceptives and HRT formulations, masculinisation of female foetuses was observed. Side effects: Adverse reactions observed in clinical trials: Very common (≥1/10); common (≥1/100 to <1/10); uncommon (≥1/1,000 to <1/100); rare (≥1/10,000 to <1/1,000); very rare (<1/10,000); and not known (cannot be estimated from the available clinical trial data). Very common: Application site erythema, Application site pruritus, Application site rash, Application site reaction. Common: Hypersensitivity, Depression, Insomnia, Anxiety Nervousness, Paraesthesia, Headache, Palpitations, Hypertension, Varicose veins, Vasodilation, Abdominal pain, Diarrhoea, Nausea, Rash erythematous, Arthralgia, Back pain, Breast pain, Cervical polyp, Endometrial hyperplasia, Genital discharge, Dysmenorrhoea, Menorrhagia, Menstrual disorder, Metrorrhagia, Pain, Oedema, Application site oedema, Fatigue, Weight increased. Uncommon include: Candidiasis, Myalgia, Oedema, Oedema peripheral. Rare: Epilepsy, Thrombosis. Frequency not known include: Breast neoplasms, Endometrial cancer, Cerebrovascular accident, Deep vein thrombosis, Pulmonary embolism, Abdominal distension, Cholelithiasis, Stevens-Johnson syndrome. Package Quantities & Cost: Each carton box has 8 or 24 TDSs in individual foil lined sachets. Cost: 1 x 8 £13.00; 1 x 24 £37.22. Marketing authorisation number: PL 49105/0009. Marketing authorisation holder: Theramex HQ UK LTD, Sloane Square House, 1 Holbein Place, London SW1W 8NS, UK. Legal classification: POM. Date of Preparation: January 2020: THX_GB_PI_001473. Please consult the Summary of Product Characteristics for other adverse reactions and full prescribing information the foetus. At doses higher than normally used in oral contraceptives and HRT formulations, masculinisation of female foetuses was observed. Side effects: Adverse reactions observed in clinical trials: Very common (≥1/10); common (≥1/100 to <1/10); uncommon (≥1/1,000 to <1/100); rare (≥1/10,000 to <1/1,000); very rare (<1/10,000); and not known (cannot be estimated from the available clinical trial data). Very common: Application site erythema, Application site pruritus, Application site rash, Application site reaction. Common: Hypersensitivity, Depression, Insomnia, Anxiety Nervousness, Paraesthesia, Headache, Palpitations, Hypertension, Varicose veins, Vasodilation, Abdominal pain, Diarrhoea, Nausea, Rash erythematous, Arthralgia, Back pain, Breast pain, Cervical polyp, Endometrial hyperplasia, Genital discharge, Dysmenorrhoea, Menorrhagia, Menstrual disorder, Metrorrhagia, Pain, Oedema, Application site oedema, Fatigue, Weight increased. Uncommon include: Candidiasis, Myalgia, Oedema, Oedema peripheral. Rare: Epilepsy, Thrombosis. Frequency not known include: Breast neoplasms, Endometrial cancer, Cerebrovascular accident, Deep vein thrombosis, Pulmonary embolism, Abdominal distension, Cholelithiasis, Stevens-Johnson syndrome. Package Quantities & Cost: Each carton box has 8 or 24 TDSs in individual foil lined sachets. Cost: 1 x 8 £13.00; 1 x 24 £37.22. Marketing authorisation number: PL 49105/0009. Marketing authorisation holder: Theramex HQ UK LTD, Sloane Square House, 1 Holbein Place, London SW1W 8NS, UK. Legal classification: POM. Date of Preparation: January 2020: THX_GB_PI_001473. Please consult the Summary of Product Characteristics for other adverse reactions and full prescribing information bleeding. Previous idiopathic or current VTE. Active or recent past ATE disease. Not indicated, treatment should be withdrawn immediately. Data on a limited
1. Theramex Data on File Mar 2021. Based on the number of prescriptions written for transdermal HRT 1. Theramex Data on File Mar 2021. Based on the number of prescriptions written for transdermal HRT in the UK and confirmed at time of publication. 2. Evorel® Conti Summary of Product Characteristics. in the UK and confirmed at time of publication. 2. Evorel® Conti Summary of Product Characteristics. HRT: Hormone Replacement Therapy
HRT: Hormone Replacement Therapy
Adverse events should be reported. Reporting forms and information can Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard or search for MHRA Yellowcard in the Google Play or Apple App store. Adverse events should also be be found at www.mhra.gov.uk/yellowcard or search for MHRA Yellowcard in the Google Play or Apple App store. Adverse events should also be reported to Theramex on medinfo.uk@theramex.com or Tel: 0333 0096795
reported to Theramex on medinfo.uk@theramex.com or Tel: 0333 0096795 Evor_GB_PRNTAD_003174 Evor_GB_PRNTAD_003174 Date of preparation: March 2021 Date of preparation: March 2021
