Sex can be a difficult topic for many women to discuss.
As an OB-GYN, I know many women have concerns about sex in their relationships but are afraid to bring up the topic with their doctor (and often with their friends).
Talking about sex often requires more time than a regular doctor’s appointment allows because of various reasons: sex is a very personal issue, there are usually several components involved, and there is not often a quick fix.
In addition, sex after menopause can be even more complicated, because as women’s hormones change, four major issues may occur:
- Decreased desire or libido
- Increased body and self-image issues
- New relationship issues
- Pain with intercourse
Any or all of these factors may affect how often a couple has sex and how satisfying it is when it occurs.
Unfortunately, sex issues can harm or even destroy even the strongest relationships if these issues are not addressed.
A woman I’ll call Sally is an example of someone who suffered needlessly and desperately sought help.
She came to see me because of pain with intercourse, and she explained that although she and her husband had experienced a good sex life for many years, the pain was now keeping her from wanting to be intimate.
Sally found herself doing anything she could to avoid the topic of sex, including steering clear of romantic movies, music, or opportunities where they might have the chance to have intercourse. She would stay up late, fall asleep in a chair while watching television, or wake up much earlier than her husband.
Sally didn’t want to turn him down or make him feel bad, but she was afraid to have sex and even more afraid to tell her husband it hurt. She didn’t know how to start the conversation with him.
Sally’s dilemma was something I have heard many times, so I started by asking her specific questions and getting more of her recent medical history.
Overall, she was feeling healthy. She told me her menopause had started about four years earlier and her periods had stopped completely. Her hot flashes had not lasted long, and she was now sleeping well and not experiencing any other symptoms. Although Sally had gained a little weight during menopause, she was still very active and ate a balanced diet—very little sugar or alcohol.
This was all good news.
In addition, she had a job she liked and a strong group of friends. With her kids all grown and established in their lives, she and her husband looked forward to spending some quality time together.
This sex issue was really throwing a wrench in their plans.
Further discussion with Sally revealed she had decided not to take hormones because her symptoms weren’t that bad and she had heard they could cause cancer. She also wasn’t taking any other medicines regularly. There were no signs of vaginal discharge, itching, or other common conditions. Her only complaint was the pain during sex.
After talking more in depth with Sally, she began to see some areas that could be improved with her husband. After their kids left home, Sally and her husband had fallen into a habit of eating together and then watching television before bed.
They didn’t do much together as a couple and realized they didn’t have much to talk about anymore. They did socialize with friends, but the couples would typically separate into two groups—wives and husbands.
They both enjoyed traveling, but lately they had been so busy with work and their separate activities, they couldn’t find the time to take any trips together. Sally realized they had begun to grow apart, although she felt they were still in the safe zone.
Next, I performed a physical exam on Sally and found that she didn’t have a bacterial infection (very common) or a skin condition called lichen sclerosis (also common). However, she did have what I expected—Genitourinary Syndrome of Menopause, also know as vaginal dryness.
The skin was dry, and the normal structures almost looked shrink wrapped. In addition to the skin changes, Sally also had tight, painful pelvic muscles.
After the exam, we talked about Sally’s options.
I explained that her condition was common and fixable. Sally’s symptoms were due to a lack of estrogen in the skin, causing skin thinning, dryness, and loss of the ability to make lubrication.
The opening to her bladder was also tilted, increasing her chance of a bladder infection. This condition affects more than 90 percent of women who are not on hormones.
Her tight pelvic muscles could be caused by poor strength in her core muscles, too much constant tension in her strong belly muscles, or possible hip problems.
I recommended vaginal estrogen, which comes in three different forms: cream, pills (for the vagina), and a three-month ring with slow release. Sally opted for a small amount of the cream, applied just inside the vagina twice a week.
I assured her that this estrogen would not be absorbed into her system as I knew she was concerned about estrogen causing cancer.
I also recommended a dose of vaginal valium used in her vagina an hour before intercourse to help the pelvic muscles relax. If that was not effective or Sally wanted more information, I recommended she visit the Spectrum Health Pelvic Floor physical therapists for education on treating tight muscles and relieving pain.
By the end of her visit, Sally said she was encouraged about her treatment options. She was also motivated to start thinking about her relationship with her husband and planned to have a conversation with him about spending quality time together.
I’m happy to say that when Sally came back to see me several months later, she had only used three of the valium pills and could now be intimate without pain.
All of the other symptoms had improved, and she felt really good about the direction she and her husband were heading. She felt closer to him and did not have to avoid being alone with him anymore.