Menopause. It’s something most women will go through, yet still so shrouded in secrecy, shame and sexist jokes.
But menopause can be a time of real vitality for many women, as they gain a greater sense of confidence and empowerment – as long as they receive understanding and support. Both healthcare and cultural awareness surrounding menopause has improved vastly over the past decade, with GPs and therapists committed to helping women with not only their physical and emotional health, but their sexual health too.
While some women can experience physical and emotional changes during menopause that can affect libido or physical pleasure, this doesn’t mean that menopause must mark the end of a satisfying sex life. On the contrary, menopause can open up new explorations of pleasure and intimacy – we just need to be willing to talk about it, and adapt.
Changes in the body
During menopause, many women experience changes to their vaginal canal, vulva, bladder and urethra, because they are all covered in oestrogen receptors. Oestrogen plays several important roles, including stimulating the production of lubricant and dictating the pH balance of the area. When oestrogen levels change, not only can lubrication stop but the bacteria in the reproductive organs can change, resulting in vaginal dryness, recurrent urine infections, or bacterial vaginosis, all of which can result in pain and discomfort. Physical changes such as a loss of collagen affect the vagina too.
“You lose about a third of your collagen at the time of menopause,” explains Dr Caoimhe Hartley, who set up the Menopause Health clinic in Dalkey, Co Dublin. She is also part of the multidisciplinary team in the new specialised menopause clinic in the Rotunda Hospital. Other menopause clinics have recently opened in the National Maternity Hospital and the Coombe and Nenagh hospitals, with two more due in Cork and Galway.
It’s also important for women to know that if they have had a negative experience with a GP before, that they should seek out another doctor, because women deserve adequate care – and it is available
“We lose some of the stretchy flexibility that you have in the vaginal canal. When you look inside someone’s vaginal canal, it’s folded, like it should look like an accordion; that allows for stretch and give with things like inserting a tampon or penetrative intercourse,” Dr Hartley says.
“[In menopause] you lose oestrogen, and you lose that collagen. The vaginal canal becomes shorter, so tightens a little, the walls become thinner, they’re drier, things tear much more easily. We see this constellation of symptoms happening where people lose lubrication, the area gets drier, but also people get recurrent urine infections, increased urinary frequency, they get new incontinence.”
These issues can cause pain for women during everyday activities likes cycling. Even wearing panty liners or using toilet paper can cause irritation and contact dermatitis. “They’re in this kind of vicious cycle then,” says Dr Hartley. “And then they’re too embarrassed to talk about it. Or they don’t want to get a smear, because sex is so painful they postpone their smear, and that has an impact on cervical health.”
Dr Hartley stresses the importance of women raising any form of vaginal discomfort with their doctors, because help is available. “It is the most easily treated of all of the menopausal symptoms,” she says. “It’s so easy to treat vulva vaginal atrophy with localised oestrogen. It’s pretty user friendly, and it’s really, really, really effective.”
Naturally, if women are experiencing vaginal dryness, irritation and infections that can make penetrative sex painful, this can reduce desire for any form of penetration.
Meanwhile, decreased blood flow to the vulva area can reduce the sensitivity of the clitoris, which can mean that some sexual activity that used to provide pleasure is no longer as effective. These factors, along with the mental and emotional impacts of menopause, can have a huge impact on women’s libido.
Changes in the brain
While we often associate menopause with the body, reproductive organs and ageing, what is happening is actually a natural and impressive form of adaptation by the brain.
“The majority of your symptoms are actually not related to your ovaries at all,” Dr Hartley explains. “They’re coming from your brain. Your hypothalamus, a part of your brain, that’s what triggers or controls these hot flushes, that’s where your thermostat is. And obviously the mood and emotional and cognitive symptoms, even libido, a lot of that comes from your brain, not your genitals.
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“So what’s happening is not ageing. It’s an adaptive process. And that’s what gets lost so much in the media – it’s not like we hit menopause and that’s it, ‘I have changed, inherently changed and I’m old.’ What’s happening is your brain is realising it’s in a new environment, so you no longer have oestrogen, or oestrogen levels are fluctuating if you’re perimenopausal, because your brain is saying ‘I’m in a new environment’ and it’s trying to adapt – and it does adapt for most women.”
Seeking medical help
There are many treatment options available, including the use of localised oestrogen, hormone replacement therapy (HRT), looking at other medications such as antidepressants which could affect sex drive, and the use of testosterone which can be helpful for some women.
Cognitive Behavioural Therapy (CBT) has also proven effective in the management of menopausal symptoms, and some sexual difficulties can be improved using vaginal moisturisers, lubricants or vaginal oestrogen pessaries, all of which can be discussed with your GP.
Many women can feel embarrassed to bring up their sex life with their GP, but helping patients with all facets of their health, including their sexual health, is exactly their job.
“If women are struggling with mood disturbance or sexual difficulties, they should speak to their GP who will address the issue sensitively and offer some management strategies that may significantly improve their quality of life,” says Dr Ciara McCarthy, the first ever clinical lead in women’s health for the Irish College of General Practitioners (ICGP).
As well as training programmes for GPs in women’s health, the ICGP have also produced educational videos on menopause for patients to help them feel supported and confident when speaking with their doctor about issues like libido and sexual pleasure.
“There has been a huge uptake of menopause education by GPs in the last number of years,” Dr McCarthy says, “which is mirrored by increased prescriptions of various HRT preparations. This upskilling by GPs in the face of evolving best practice should reassure women that GPs have responded in a positive manner to increased awareness around menopausal symptoms, and the importance of good postmenopausal health.”
While for some women the idea of asking a GP about their sex life, libido or vaginal health might be “too much information”, rest assured that in medicine, there’s no such thing.
Something that can be empowering for women is to become a sexual protagonist in the relationship, so your partner doesn’t solicit you, and you feel in control— Helen Mayor, integrative psychotherapist, psychosexual and relationship therapist
“I look at vaginas all day long!” Dr Hartley laughs. “There’s no such thing as too much information. It’s exactly what I’m for. And it is absolutely okay and important to ask these questions.
“I think there’s a huge stigma still attached to that, but women need to know we’re here to help. Loss of libido is in the top few symptoms that we hear about, but still women can feel embarrassed and think it’s just them.”
It’s also important for women to know that if they have had a negative experience with a GP before, that they should seek out another doctor, because women deserve adequate care – and it is available.
Affection and connection: How partners can help
It’s important to acknowledge that most of the research into the impacts of menopause on women’s libido and intimate relationships are centred on heterosexual women in relationships with men, and cultural scripts around sex have often prioritised penetrative intercourse above all other forms of sexual activity. This means that often, women in relationships with men can feel under pressure to continue having penetrative sex even if it is painful or uncomfortable for them – and this needs to change. Just like menopause itself is an adaptive process, sexual partners can and must also adapt to the changing realities of their bodies.
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For some couples, this may mean happily reducing the amount of sex they are having and finding other ways to stay connected. For others, this may just mean expanding the definition of what sex and intimacy means for them – and having fun exploring new forms of intimacy, eroticism and sensuality.
Sex is not limited just penetrative intercourse, and women going through menopause might find that there’s greater pleasure in other sexual activities, such as enjoying oral sex, an erotic massage and using powerful vibrators which can still provide pleasure without causing any discomfort. Couples can use this time to experiment and try new forms of touch to discover what feels good for them. Taking this time to play, explore and remain intimate cannot only open up new ways of experiencing sexual pleasure, but are also ways to remain connected emotionally.
If we don’t feel good about our bodies, we’re much less likely to reveal it or want it touched— Helen Mayor, integrative psychotherapist, psychosexual and relationship therapist
A huge issue that can affect couples when one partner is going through menopause is when all forms of physical intimacy and affection shut down completely. This can be caused by a lack of understanding around the shift in sexual desire and pleasure for some women during this time.
Helen Mayor is an integrative psychotherapist, psychosexual and relationship therapist based in London. She reports that a repeated issue she encounters with couples is when a woman experiencing menopause does not want to have sex, and fears that any form of physical affection with their partner such as kissing, hand-holding or cuddling will lead to a sexual advance or escalation – and so they withdraw completely from all forms of affection and intimacy.
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This withdrawal can damage romantic relationships. “Massively,” Mayor emphasises. “The amount of people that withdraw touch, or affection of any kind, because they see it as a segue or a risk of a segue into sex is huge. And people should talk about it.”
Mayor suggests that male partners often don’t understand the physical changes for partners experiencing menopause, and opening up that conversation can open up the opportunity for more understanding – and more exploration as to what can be pleasurable for women now.
“Something that can be empowering for women is to become a sexual protagonist in the relationship, so your partner doesn’t solicit you, and you feel in control,” says Mayor. “And it can be can make people think a bit more about how to approach and prioritise sex. But it’s so important to still have touch, to create ongoing forms of affection and connection.”
An increase in perspective, wisdom and self-confidence can lead to a greater sense of authenticity and freedom – and there’s nothing sexier than that— Helen Mayor, integrative psychotherapist, psychosexual and relationship therapist
For women whose libido has been affected by menopause, spontaneous desire may not be as regular as it once was. However, prioritising time for emotional connection and physical affection will be hugely beneficial to the emotional health of a romantic relationship – and for those who do want to maintain an active sex life, it will create the opportunity for sexual desire to build.
“I say to people, it’s about desire changing from ‘I look across the room, I see you look hot, I want to take your clothes off and have sex again’, to making the effort,” says Mayor. “I like saying, one is like turning the heating on – you just go flick a switch and it’s there. And the other is like building a fire. And you have to make sure you’ve got the logs in, you have to make sure you’ve got a match, you can have some kindling, sometimes the fire might go out, you have to keep trying. You have to keep putting the effort it – but it’s worth it.”
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Mayor recommends trying new things together, as well as regularly going on date nights where you get ready separately, get dressed up to the nines, and have conversations that go beyond daily routine and let you really connect. “It’s asking questions like ‘If you had to do any career, now, what would you do?’ It’s how do you open up conversation,” she says.
“How do you try to find things about your partner that you didn’t know? Are you prepared to try and bring something new into something old? Are you prepared to take up a new hobby together, like go dancing, to do yoga? Are you prepared to do things together and separately that make you feel good about your body – because if we don’t feel good about our bodies, we’re much less likely to reveal it or want it touched.”
Whether partnered or not, women experiencing menopause should invest in their own sensuality and embodied pleasure to remain connected with their bodies. This can include masturbation, dance classes, staying fit and active, or simply treating themselves to massages or long baths, so that they continue to find forms of pleasure and enjoyment in their bodies.
Sometimes, the greatest challenge to women experiencing menopause is making sure their romantic partners can keep up with them. For many women, menopause can be an incredibly liberating time. For mothers, their children may be out of the house, giving them more time to cultivate passions and social relationships. Without the risk of pregnancy, sex becomes not about procreation, but recreation. And an increase in perspective, wisdom and self-confidence can lead to a greater sense of authenticity and freedom – and there’s nothing sexier than that.