the time when the production of hormones, chiefly estrogen and progesterone,
dramatically decreases, bringing an end to the menstrual cycle and
fertility. While many women welcome the cessation of menstruation,
they may not have realized how strongly it was connected to their
self-image of being feminine and sexual.
menopause in diverse ways. There may be a sudden onset due to surgery.
Hot flashes and erratic menstrual periods signal the approaching
change for some. Others may have noticeable mood swings, depression,
or insomnia. If these symptoms are severe enough estrogen is prescribed.
Embarking on Estrogen Replacement Therapy (ERT) or Hormone Replacement
Therapy (HRT) plunges a woman into the debate over whether the acclaimed
benefits of taking ERT/HRT including protection from heart disease
and osteoporosis, outweigh the risks of getting breast and uterine
cancer, blood clots, and high cholesterol.
In the midst
of that debate sexuality issues often get lost. Yet these issues
may be of more immediate concern, particularly; the light to extreme
vaginal dryness which results in painful sex, and diminished sexual
desire. These symptoms do not effect all women, just as many women
never experience hot flashes. But when they occur they are inescapable
and complex to treat.
How much personal
or professional help a woman gets with her changing sexual feelings
and physical responses may depend on how comfortable she is with
her own sexuality. The degree to which she has felt sexually safe,
accepted, and desired during her growth from girl to woman will
effect how satisfactorily she can voice her needs to her doctor
and sexual partner.
levels decrease blood flow to the vagina setting up a series of
falling dominoes. Decreased lubrication can make vaginal friction
and penetration uncomfortable or painful. Without lubrication a
woman may think that she is not sexually turned on, which can lead
her to question her affection for her partner. The discomfort or
pain may be severe enough for her to avoid sex and even physical
affection if it might lead to sex. If masturbation was a pleasurable
part of her sexuality (whether partnered or not) she may think she's
lost interest in herself! There may even be a feeling of shame that
the lubrication she took for granted as part of being a sexy woman
is gone, and thus the whole sexy woman is gone too. It compares
to the shame that a man feels as his erections become less reliable
It is likely
that if a woman's sexual history includes sexual abuse, or a long
or short-term unsupportive or incommunicative partner in the bedroom,
her sexuality will fare no better with the changes menopause brings
about. For example, unresolved relationship issues including money,
balance of power between partners, difference in child rearing styles,
and involvement with extended family, can all have an impact on
a couple's sexuality. If one partner in the relationship (either
male or female in a heterosexual one) carries intense anger or contempt
for the other, withholding sex becomes a powerful weapon and may
already be part of an established pattern; a lose-lose situation
In our youth
-oriented society, the menopausal woman is encouraged to restore
what she is losing through ERT or HRT. Certain hormone treatments
(estrogen, progesterone or testosterone) usually assuage menopausal
symptoms such as vaginal dryness and hot flashes. Some women even
report restoration of energy, memory, improved skin condition, and
overall well-being. What is still up for grabs is the optimum dosage,
length of time, and best hormonal combination to take in order to
maximize the benefits while reducing the risks. Just as women weighed
and chose the risks, benefits, and side effects of birth control
pills, IUDs, and other birth control devices we do so again with
And like birth
control ERT/HRT is highly political. There is a growing number of
wonderful books on menopause, many of which reflect different biases.
Often an author shows preferences for or against ERT/HRT, and for
or against synthetic, plant or animal-derived compounds. In some
books, sexuality takes center stage, and it seems to make perfect
sense to take hormones to restore sexual vigor and interest. In
others you might conclude that you would be making a bargain with
the devil by risking cancer and blood clots for a good lay.
accuse "the feminists" of portraying hormone therapy as
a conspiracy of the male dominated medical model that considers
menopause to be a disease, and a conspiracy of the billion-dollar
drug industry that has profited from ERT/HRT sales. While there
is objective truth to these interpretations, a woman may not know
herself what drives her choices; concerns for her health, or anger
at the drug industry or the male dominated medical establishment.
What about the "naturalness" of the most widely prescribed
estrogen compound which is derived from the urine of pregnant mares?
A vision of barns of pregnant mares being milked for their urine
could make a woman become a vegan! (Don't laugh, soy is a good source
of estrogen). I don't even want to think about how testosterone
might be collected!
If vaginal dryness
is the only problem, the many water- based lubricants from the drug
store may suffice. If they don't eliminate pain during sex, a locally
applied estrogen cream taken in specific doses and for specific
periods of time can thicken vaginal walls and restore vaginal secretions.
If a woman is uneasy about estrogen absorbed systemically by pill
or patch, estrogen cream allows her to choose the lowest dose for
maximum effectiveness. Vaginally applied estrogen cream should not
be used as a lubricant and should not be applied before heterosexual
sex, as estrogen absorbed through the penis has been associated
with tumor growth in men. Condom use is sometimes suggested for
full protection in such cases.
(with or without progesterone) may resolve hot flashes and vaginal
dryness, many women on ERT/HRT still report no restoration of a
libido or sexual desire. The literature is confusing as to estrogen's
impact on sexual desire.While many writers would agree with Susan
Love's statement that "no correlation has yet been found between
estrogen and sexual interest", 1Lonnie Barbach reports a Yale
University study showing that "90 percent of the women who
had experienced a lack of desire before the study reported an increase
in desire after being treated with estrogen for three to six months."
I believe that
what is being confused is the difference between sexual drive and
sexual desire. The desire to have sex may be there, but the drive
or visceral urge may not be. A woman may desire to engage in sexual
relations anticipating good feelings, relaxation after orgasm, or
increased closeness with a partner, yet still not feel the sexual
urge in her groin or however she has been accustomed to experiencing
being "horny". As with the gradual disappearance of natural
lubrication, the loss of the sexual urge may make a woman, and/or
her partner, believe that she no longer wants sex, or doesn't want
it with her partner. For many women, this happened long before the
onset of menopause, but for those for whom this is a new loss, it
is deeply missed.
argues that "desire is a function of expectation and memory,
and if we remember negative experiences we can lose our desire".3
Acute symptoms of menopause (hot flashes, insomnia, moodiness, etc.)
certainly can erode sexual desire. To the degree that estrogen ameliorates
these symptoms, desire may return if a woman is willing to engage
in sex in the absence of the sexual urge. She may not have the same
sexual experience she used to have ten or twenty years ago, but
that is more a function of aging, not of menopause. Many women report
that while they may not feel like having sex, once they become open
to a willingness to be intimate they can usually get turned on.
This is a good example of using the other sex organ, the brain.
What about testosterone,
the male sex hormone credited with male sex drive? Women produce
testosterone at about ten per cent of male levels. While production
levels of total hormones decrease in menopause, it has been pointed
out that women's testosterone levels increase proportionally as
estrogen levels decline. While testosterone in various forms (pills,
shots, pellets, patches, and creams) is prescribed for women with
absent sex drive, there is less long-term research than for estrogen
on the safety and efficacy of dosage size and length of use. For
some women it has worked well, others have experienced only short-term
benefits. There is concern that long term use in large doses can
adversely affect cholesterol levels and the liver, and produce secondary
male sex characteristics like a lower voice, and increased body
hair. Caution and close physician monitoring are recommended with
For some menopausal
women, it is their partners whose sexual interests have changed.
It is common enough for men to experience erection failure or impotence
due to aging or the side effects of drugs for chronic medical conditions.
They may feel so much shame and performance anxiety that they would
rather forego sex altogether than be treated. Experimenting with
drugs like Viagra or devices like penile implants after prostate
cancer surgery, for example, can stress a couple's sexual life,
beyond living with and surviving a life threatening disease. Open
communication and couple's counseling might help a couple through
There are also
many psychosocial factors that can at least temporarily deaden sexual
drive and activity. The many social, familial, and professional
changes midlife women experience may at first be felt more strongly
as losses than as opportunities for new growth: children leaving
home; the stopping of the biological clock for women who didn't
have children; new single status through divorce or death of a partner;
diminished ability to compete professionally with younger women,
or workplace pressures to retire; new dependence or death of a parent;
health problems associated with aging. We need to do the necessary
grieving for these losses before we can move on to the transformational
opportunities they can offer us.
more than knowing you are not alone. And you are not. Check out
the growing number of books on menopause, share these issues with
your partner, and your friends. Start a menopause support group.
We are on a bridge to the next stage of our lives, and the discoveries
we make now will brighten what comes next.
" The Pause: Positive Approaches to Menopause", New York:
Signet Books, 1994.
Love, S. "Dr.
Susan Love's Hormone Book", New York: Random House, 1997.
"I'm Too Young to Get Old", New York: Times Books, Random
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