I have lost my interest in sex lately, said  Barbara, a 51 year old mother of three who had just entered menopause six months prior to her visit with me. These hot flashes are constantly waking me up during the nighttime, and I am so moody that I can’t control my own emotions.  Frankly, it just hurts too much to have sex. 

Menopause heralds a transition in a woman’s life. Her stable, regular menstrual cycles have been replaced by either erratic menstrual patterns or the cessation of menses, both of which are associated with weight gain, mood disturbances, hot flashes and a decrease in sex drive. 

Prior to menopause, the ovaries produce an abundance of estrogen and progesterone, hormones which help to maintain skin elasticity throughout the body, including the genital area.  Once estrogen production begins to decline in the menopause, the vaginal tissue often becomes dry and less elastic, often leading to narrowing, itching, burning and consequently painful intercourse. Tissues surrounding the vagina, such as the urethra  and bladder are also adversely affected by a lack of estrogen, leading to painful urination, a constant urge to urinate or  frank incontinence, which may occur during intercourse. 

The pain and discomfort associated with this lack of estrogen known as atrophy causes disturbances in sexual function. Intercourse, which was once pleasurable and desirable, now causes burning, small tears and oftentimes, mild bleeding in the vagina. 

Menopause is also associated with a lack of sex drive or libido. The midlife is often associated with a number of changes in a woman’s family and social life. Children often have left the household or she may find herself newly single after a divorce, having to enter a new and sometimes frightening world of dating.  New relationships often mean coping with sexually transmitted diseases and practicing safe-sex, a concept that never entered a mature woman’s mind when she married her high-school sweetheart in the 1960’s.  

The midlife is also associated with chronic medical illness such as diabetes, hypertension, cardiac disease and cancer. These conditions and the medications prescribed for these conditions may adversely affect a woman’s body and mind, ultimately leading to a decreased libido. 

Hormone replacement therapy (HRT) remains the standard treatment for menopausal symptoms. The quantity and duration of hormonal therapy is and will continue to be a subject of debate for years to come.  Estrogen, in pill, patch or lozenge form is combined with progesterone if a woman has an intact uterus in order to protect the uterine lining from overgrowing, a condition know as hyperplasia. A woman who has undergone a hysterectomy does not necessarily need progesterone in her HRT, however, studies have shown that natural micronized progesterone actually improves cholesterol profiles and protects women from osteoporosis. 

Hormone replacement therapy stops the hot flashes that lead to disturbed sleep patterns, thereby improving a woman’s mood and energy levels. HRT benefits a  woman’s skin, hair, nails and vaginal mucosa, leading to a better self-image and a more comfortable sexual experience. Other non-hormonal therapies that improve sexual pleasure include water-based lubricants such as Astroglide or K-Y liquid.

It is essential to communicate with your health care provider about problems such as vaginal atrophy or decreased libido in the menopause.  Keep in mind that your sexuality is a health issue and has just as much bearing on your overall health as any other medical problems.

Tara A. Solomon, MD

Back Page