Estrogen, as you know all too well these days, does a lot of good things for your body and your mood. Maybe you didn’t know that it also does a lot of good things for your brain.
“In preclinical studies, estrogen was shown to improve energy production, reduce oxidative stress, increase brain cell survival during damage, enhance the release of protective chemicals, and improve memory,” according to this recent article.
So, you may ask, what the heck happens in the brain when estrogen disappears after menopause? Researchers are also asking if estrogen, or the lack thereof, plays a role in Alzheimer’s disease, the most common form of dementia, which disproportionately affects women.
Neither menopause nor lack of estrogen is directly linked to dementia, or specifically, to Alzheimer’s disease. No smoking gun or causal connection has been found despite numerous studies comparing women who have taken estrogen with those who haven’t.
“…Evidence from cohorts in Melbourne, the United Kingdom, and rural Taiwan suggests that the natural menopausal transition probably does not have important effects on episodic memory or most other cognitive skills,” states this National Institutes of Health (NIH) article.
So, what does happen in the brain when estrogen production declines after menopause? Are all those “senior moments” really the result of our estrogen-starved gray matter? Does estrogen replacement therapy (ERT), have any effect on brain health? Finally, although no treatment exists for Alzheimer’s disease, could estrogen play a role in preventing or delaying its onset?
While these are all tantalizing questions that researchers are beginning to tease apart, no actionable answers are forthcoming, yet. Frankly, research results are all over the map. You may remember the groundbreaking 2002 Women’s Health Initiative that was responsible for a seismic shift in the routine use of estrogen therapy after concerns about risk of breast cancer and heart disease--some of which were misunderstood or at least miscommunicated.
Less well-known was that a cognitive component to that study (the Women’s Health Initiative Memory Study) found that the risk of dementia increased, sometimes dramatically, for women over 65 who were on hormone therapy.
However, several recent studies suggest that beginning hormone therapy at a younger age may have a protective effect on the brain. A recent study in Norway and another in Finland determined that taking estrogen before and during menopause, resulted in increased brain volume, especially in the hippocampus, which is the area associated with memory and sense of place and which is most disrupted by Alzheimer’s disease.
These conflicting results have led to the “critical window” hypothesis: that at some points in the menopausal transition, estrogen may help preserve brain function while at others, not so much.
“Most researchers seem to accept the idea that a critical window exists during which estrogen treatment is most likely to be beneficial. ‘The question is, when is that window open, and when is it closed?’ ” said Roberta Diaz-Brinton.
Diaz-Brinton suggested that healthy cells may be more likely to respond positively to estrogen but older or “sickly” cells may not. This is the “healthy cell bias of estrogen.”
Frustratingly, for those of us approaching menopause, the data continues to roll in and not much is consistent enough to define a course of action. Obviously, a bunch of variables confound the picture: how the estrogen is administered (whether by pill or patch); what kind of estrogen is administered (bioidentical, equine, or some other formula); certain genetic factors; the combined effect of estrogen plus progestogen (for women who still have a uterus); plus all the other variables of country, culture, health, and lifestyle.
The current position of the NIH, which can be expected to take a conservative position, is that “it is unknown whether estrogen effects on Alzheimer risk are modified by age of use or by use during a critical window close to the time of menopause.”
Probably the most reasonable course of action is to continue to follow general medical guidelines to take the smallest dosage of estrogen for the shortest period of time to relieve menopausal symptoms. According to the most recent studies, that’s when it might do your brain the most good. Beyond the menopausal years, evidence suggests that it either has no effect or it has a negative one.
And, for our daughters’ sake if not our own, let’s continue to speak out about the importance of research in women’s as well as men’s health. We are not the same.
Getting old ain’t for sissies, and neither is menopause. For all you guys out there with menopausal partners, maybe you’ve noticed her, um, lack of patience. Maybe you’ve been caught in the crosshairs of her mood swings. Maybe you’ve been awoken at night to her tossing and night-sweat-induced turning.
And maybe she just isn’t interested in sex anymore.
In my practice, I usually hear the woman’s side, but I know you’re an uncomfortably intimate co-pilot on this journey. You may be feeling confused, hurt, rejected, and helpless. This person you thought you knew is changing before your eyes. You don’t know how to help; you don’t know what this means—and it seems to be going on forever.
You miss the sex, the intimacy, the person you used to know. You miss the way things used to be, and you don’t know if or when any of these things will ever come back.
You aren’t alone. Says 70-year-old Larry in this article: “When she got to about 65 it started to change. Intercourse became painful for her and she developed an allergy to semen. Now intercourse is out of the question and she has no desire for anything other than hugs.”
Life—and sex—does change during menopause, but that doesn’t mean you’re doomed to a relationship without intimacy forever. Shifting ground is treacherous, but with some work on both your parts, you’ll weather the storm, and emerge stronger than before.
Here’s what you can do:
Walk a mile in her shoes. Depending on the intensity of her symptoms, your partner is going through moods that may swing wildly without rhyme or reason, and over which she has no control. She may experience uncomfortable and embarrassing hot flashes frequently and unpredictably. She may toss and turn at night, waking soaked with sweat.
She may gain weight, lose her hair, and generally grow old before her own eyes. This can be particularly galling in a culture that is completely besotted with youth and beauty. “A woman’s self-esteem influences her sexuality, and low self-esteem is associated with sexual dysfunction,” according to this article.
What you can do: Educate yourself on menopause. Understand the trajectory and the tortuous path it takes. Read this blog. Learn about comfort measures and possible treatment options. There are many. She may be too embarrassed or miserable to do her own research or even to bring it up.
Armed with understanding, you can reassure and support. You can say, “You seem pretty down [or angry, or forgetful]. Are you okay? What can I do to help?” That alone may make an intimate connection, but this isn’t about sex right now. This is about reaching out to your lover who’s going through one of the most significant transitions in her life.
Now that you’ve asked, listen. And keep listening. Be an ally and a partner in this journey. Check in frequently to see how she’s feeling. Don’t advise unless you’re asked. Just listen. If she talks with her girlfriends, fine. But let her know you’re in her court. Most important—reassure her that she’s still beautiful to you. Girlfriends can’t do that.
Follow up with actions. Don’t sit on the couch while your partner makes dinner and then watch the game while she cleans up. Nothing says love like taking out the garbage or doing the dishes so she can take a bath. Once in a while, go out of your way. Cook a special, romantic meal. (You can order from one of those home-delivered meal plans, like Blue Apron or HelloFresh.) Send her flowers or plan a surprise getaway weekend. No expectations; no pressure—just an expression of your love and caring.
Get healthy. I harp on this all the time, but both you and she will feel a whole lot better (and feel more like sex) if you’re eating healthfully, maintaining a good weight, and exercising. You can gently encourage walks together, healthy eating, and good sleep habits. Don’t be a drill sergeant, but your good example and attempt to make it a couple’s thing can’t hurt.
Shake things up. Boredom is a slow leak in the sex balloon. I’m not talking about having sex on the kitchen table. But just exploring the array of tools and props that can add sizzle and simple comfort to the routine. Since your partner is probably experiencing the common menopausal complaints of dry vaginal tissue, painful sex, loss of libido, you’ll have to shake up the routine anyway.
You’ll need lots of foreplay, lots of lube, and some toys. Try reading an erotic story or watching a sexy movie together to get your heads in the game. Don’t downplay the effect of a romantic ambiance—candles, incense, music. Use pillows to cushion joints and prop up the bits that matter. Try positions that might relieve pressure, offer a different kind of contact, or just be more comfortable.
Take your time and maybe forgo the literal act if the timing’s off. You can kiss, cuddle, spoon. You can use your tongue and mouth. You can masturbate together. Take the pressure off the performance and focus on trust and intimacy.
Don’t take it personally if she just doesn’t respond the way she used to. It isn’t about you, and it isn’t personal.
Find a counselor, if necessary. Generally, celibacy isn’t a healthy state in a marriage. If you’ve reached an impasse, and there’s no way out, you may have to get some help. This isn’t an admission of defeat; it’s a sign of maturity and wisdom to look for help when you need it. If your wife won’t go, you need to find a therapist for yourself to acquire the emotional tools to navigate your relationship.
I’ll leave you with the beautiful and encouraging counsel from the perspective of a 40-year marriage: “…we have found ways to enjoy sex with each other that do not need penetration. Mutual masturbation and oral and always with some nice foreplay, we still enjoy each other.
“I miss intercourse…but we make it work, and it’s usually fun! I hope some men will read this and decide there’s a way to stay happy with the woman of your youth.”
Intrarosa is a new product for treating vaginal atrophy, approved by the FDA in November of 2016. It will be available by prescription only; it’s not yet in pharmacies but is likely to be later in 2017. The clinical trials for Intrarosa are favorable for treating vaginal atrophy, or genitourinary syndrome of menopause causing painful intercourse. It is an adrenal hormone, prasterone (dehydroepiandrosterone), formulated as a once-a-day vaginal insert.
MonaLisa Touch is a laser treatment for vaginal atrophy, also known as genitourinary syndrome of menopause. I explained the treatment option in a blog post a few months ago.
The treatment is quite effective for most patients, but it is costly. As a new procedure, it’s not covered by most insurance companies; without insurance coverage the expense (cost varies by region, but figure $1,500 to $2,000 for the three required treatments) is a limitation for many. The procedure needs to be updated regularly, probably about once a year for most women.
We also lack long-term data on its efficacy and side effects. We are very hopeful the clinical trials will soon be available to assure its effectiveness and safety.
“Midlife: when the Universe grabs your shoulders and tells you “I’m not f-ing around, use the gifts you were given.” —Brene Brown
I don’t know about you, but I love seeing old people in love. The way they hold hands toddling down the street. The way they go about their daily tasks having made peace with the past. I think it’s a miracle when love lasts this long and ages this gracefully.
Relationships encounter lots of challenges in the course of a lifetime, but from my own observations, which are supported by the data, the midlife transition, that somewhat fraught passage, is nothing to sneeze at. Menopause aside, the awareness of time passing often arrives unexpectedly and with surprising intensity, leading both men and women to make decisions that belie common sense, compared to which the red Corvette might be among the most benign. For example, the highest divorce rates from 1990 to 2010 occurred among couples over 50, according to this study. Concurrently, co-habitation rates among over-50s tripled from 2000 to 2013.
Whatever the cause—longer lifespan, greater economic freedom for women especially, cultural change—the fact is that something shifts when folks approach that midlife marker, and it’s often the woman who agitates for change.
This isn’t necessarily a bad thing. Periodic reevaluation and readjustment is healthy. So is honestly confronting ingrained habits and responses that ultimately stifle intimacy and deflect communication. Like a vintage car, most lengthy relationships require a major or minor tune-up now and then.
Still, midlife often opens a Pandora’s box of restlessness and dissatisfaction—the perennial is this all there is? What happened to the passion? Am I missing out? Do I really have to endure the quirks and habits of this individual for the rest of my life? What is really important? What dreams have I buried?
Those existential questions herald an important crossroad—the frontier between youth and maturity. With regard to your most intimate relationship, you can:
Major life transitions should never be done in haste. They deserve a considerable degree of mature reflection. We all know people who make fast and sometimes rash decisions in the throes of passion or as a desperate attempt to seize a day that appears to be slipping away. Amid the landmines of midlife, the baby is sometimes thrown out with the bathwater.
Here’s a little reality check.
However irresistible the urge, don’t blow up your life. Wait. Reflect. Seek counsel. The demand to create something more authentic, to realize cherished dreams is real and should be honored. But the best path forward probably isn’t over the shattered pieces of your present life.
You still have time. You can still seek your bliss, optimize potential, maybe with more freedom and effectiveness now that the kids are grown and you’re more self-confident. Start a business. Learn Chinese. Travel. The world is your oyster—just in a different shell than when you were younger.
Romantic passion is a landmine. Passion is powerful, blinding, and temporary. You can’t make good decisions in its throes. And even the most incredibly passionate relationship will inevitably fade with the demands of daily life. White-hot passion doesn’t last; it’s not meant to. And when reality checks in, the dirty socks on the floor look the same. Trust me on this one.
Talk to someone if you need to. A therapist. A friend. You can’t see things clearly (even if you think you can). Trust the counsel of someone wise and objective.
Don’t freeze out your partner. However restless and unsettled you may feel, your partner is probably not the enemy. You want to elicit support, not resistance. Anyone would feel threatened when cracks appear in the foundation of a secure life. Anyone would feel uncomprehending and maybe hurt. If, however, you are able to communicate what you’re feeling, even if it’s confused and incoherent, at least there’s a bridge rather than a canyon.
“This too shall pass,” writes blogger Deb Blum in this article. “It will pass more gracefully and completely if everyone is gentle and loving and gives the space necessary to get through this time.”
And that study about over-50 divorce rate also found that the longer a marriage lasts, the less likely it is to end in divorce. So those old folks holding hands in the park? The real deal.
You say you reached menopause (one year without a period) six years ago. Sex has become painful, and you want to “get it back.”
It’s never too late! Using a vaginal moisturizer may be of some benefit, but if you’ve had pain for several years, you may need a prescription treatment option to restore comfort. There are localized estrogens and Osphena (a non-hormonal option) that are very effective at restoring vaginal health. I have a patient who had not had intercourse in over 25 years. Within 3 months of treatment she was able to resume--and enjoy--intercourse! It is absolutely possible.
I would recommend going to a physician/provider who can do a careful exam and confirm the cause of the pain. Atrophy is the most common reason for painful intercourse after menopause, but there can be other causes as well; identifying the right cause makes all the difference to effective treatment.
With effort and follow-through it is nearly always possible to successfully restore the ability to have intercourse.
Sex after menopause can be challenging. This website and my medical practice is dedicated to addressing those challenges, so topics like dry vaginal tissue, pain with intercourse, loss of libido get a lot of press here at MiddlesexMD.
But for once, let’s turn the picture on its head. Let’s look at postmenopausal sex from the sunny side of the street.
Sure, menopause isn’t for the faint of heart. It’s a hormonal roller-coaster with a chaser of unpleasant side-effects. Sex can become collateral damage during all the turmoil.
But the big picture? The view from the top of the hill? Not so bad at all. In fact, depending on your inner resources and resolve, both sex and life after the big M can look pretty darned sweet. Some women even report experiencing a resurgence of desire, sort of golden age of post-menopausal sex.
Several elements tend to coincide during those post-menopausal years that contribute to a more serene, predictable life and the potential, at least, for a renewal of romantic zest. For example:
Granted, aging comes with challenges, and they can be unpredictable. But growing older and staying sexy is more about your attitude, and the resources you bring to bear than what’s happening below your neck. “So here’s the big reveal,” writes Barbara Grufferman in this article. “After 50, we’re at a sexual crossroads, and need to make a choice: We could go through menopause, shut down that part of ourselves, lock the door and throw away the key. Or we could embrace this new life with a sense of freedom and fun…”
So that’s the thing: it’s a choice. There are no wrong answers (unless they hurt your partner); instead, you have lots of options. Barriers to good sex are very fixable, both for men and women.
Here’s a list of simple things you can do to enjoy these golden sexual years to the full:
According to the experts, the most dependable predictor of good sex after menopause is good sex before menopause. And if it wasn’t so great before, time’s a-wasting. You can apply your hard-won life skills and your intimate knowledge of your partner to begin addressing the issues that stand in the way of intimacy and a solid sex life.
You say you’ve had a period and some breast tenderness after three years of hormone therapy (HT). I hope you’ll make an appointment with your health care provider: Any bleeding that occurs postmenopausally (after 12 months with no bleeding) is considered “abnormal uterine bleeding” and it really deserves evaluation. This is true whether or not you’re on HT.
The evaluation is usually an endometrial biopsy, a quite simple office procedure. Women on hormone therapy are at very low risk of developing uterine cancer, but we still want to make sure the proper evaluation takes place. Usually the biopsy is completely benign or normal, and we aren’t able to explain why it happened.
When the bleeding is accompanied by other associated symptoms, like breast soreness, it is tempting to attribute it to a “last hurrah” or one last period, but that is unlikely. Any missed doses of the HT or changes in dosing can occasionally contribute to some breakthrough bleeding. The most likely scenario is that the hormone therapy contributed to the symptoms of the breast soreness and the bleeding, but without any changes it’s hard to explain why that might have happened now, three years after menopause.
Again, evaluation usually confirms that all is normal, but it’s worth making the effort to be sure!
You say orgasms are new to you (congratulations!), and, having had the experience, you’re looking to explore it further. You’re not sure your clitoris matches what you’ve read in books.
The external part of the clitoris is the head or glans; the shaft is deep to that. When you touch the clitoris, you’re touching the clitoral head. With arousal, there is usually minimal “engorgement” noted for women. By comparison, think of the penis, whose head doesn’t enlarge all that much when aroused. It’s the penis shaft that enlarges, and for women, the comparable clitoral shaft is internal (here’s a blog post with an illustration, which could be helpful).
A person’s size, weight, and number of pregnancies or childbirths don’t usually alter this part of our anatomy. As we age and hormone levels decrease, the clitoris does diminish in size and there can be skin conditions of the vulva that make the clitoris more “hooded.”
The most consistent, reliable way for most women to experience orgasm is direct clitoral stimulation (for others it’s vaginal at the “G spot”), and a vibrator tends to provide that for most women. But “most women” isn’t “every woman,” so you might try warming products, which can be helpful by providing stimulation to bring more blood supply to the area.
I wish there were a single route to experiencing orgasm--or maybe I don’t. There’s something nice about it being individual and unpredictable. Continuing the pursuit is fulfilling and, I hope, ultimately satisfying, too!
The stars have aligned for our January resolutions series. Not only is January designated as Cervical Health Awareness Month, but I’d say that the cervix counts as an “often neglected body part” related to our sexual health or well-being, which was the criterion for this January resolutions series.
The good news about the cervix is that there really isn’t anything you have to do to improve its function—no exercise, no diet, no special creams or lotions. Basically, it’s four centimeters of tough muscle between the vagina and the uterus. It keeps a baby in safely tucked inside the uterus and then dilates when it’s time for the baby to be born. That dilation is what labor is all about, as though you could ever forget. It really has no sexual function, contrary to previous belief.
The deal with the cervix—and why we have this special month devoted to it—is that you can almost ignore it if it’s healthy, but if it acts up, as with cervical cancer, then you have a problem, Houston.
And that’s why you can’t completely ignore it. So let’s give the lowly cervix a little blog luv.
Times have changed with the sexual revolution and advent of cheap, easy, and effective birth control. There’s a whole lot more sex happening with more partners, for one thing. And with that has come a lot more sexually transmitted diseases. We talked about that at length, beginning here, but as it relates to the cervix, here’s the rub.
The precursor for cervical cancer is what we call SIL (squamous intraepithelial) change (or dysplasia in physicians’ lingo). That change is nearly always caused by human papillomavirus (HPV; there are rare occasions where cervical cancer isn’t HPV related), and HPV is pretty much ubiquitous among sexually active people (80 percent). Plus, it’s a virus, so once you have it, there’s no cure. Usually that’s no problem. In 70 to 90 percent of cases, a healthy immune system clears it up within two years—kind of like the common cold.
But as we know, viruses are wily, shape-shifting critters. There are about 100 strains of HPV, only a few of which are considered high risk for cervical cancer. About 12,000 women get cervical cancer every year in the US, and one-third of them die. This isn’t a huge number, but the tragic thing about cervical cancer is no one should die from it because cervical cancer is extremely easy to detect and treat. In women older than 65 with cervical cancer, 42 percent had never been screened.
Screening guidelines and testing procedures have changed in recent years, however, so it’s no wonder if you’re confused about what to do and how often to do it. There is now a test for HPV, which is recommended for any woman over 30. There is also the tried-and-true Pap test that tests the cervix for precancerous cellular change, or dysplasia. This test is recommended to start at age 21.
A woman with a history of negative results and no other complications only needs a Pap test every three years. Combined with a negative HPV test, the wait can be five years.
Obviously, if your cervix was removed during a hysterectomy (and you DO know whether or not it was removed, don’t you?), and if you don’t have a history of cancer or dysplasia, you are done with Pap tests forever. Even if your cervix is intact, until recently the guidelines advised that women over 65 with no history of positive Pap results no longer need screenings.
All that may be changing.
In a 2013 study of women between 35 and 60 found that some women who had been monogamous or celibate for decades began testing positive for HPV. The results suggested that these women had been carrying latent and undetectable levels of the HPV virus from sexual encounters in their youth that had spontaneously reactivated during menopause. This is akin to a childhood case of chicken pox returning later in life as shingles.
“As long as you are controlling these infections, your immediate risk of [cancer] is going to be low,” molecular biologist Dr. Patti Gravitt explains in this article from Johns Hopkins. “But if menopause, or just getting old, increases HPV reactivation, then we need to look at what this means for screening these older women who came of age during the sexual revolution and are much more likely to reach menopause with latent HPV than the postmenopausal women we have screened in the past.”
In the face of this surprising finding, the North America Menopause Society now recommends that “all women who have had multiple partners should not stray too far from their Pap smear or HPV test at menopause until we know more about the increased risk of HPV flare up at menopause.”
Even women who have had their cervix removed should be aware that rarely HPV also causes vaginal and vulvar cancers. So more than ever it pays to be aware of your cervical health—and your HPV status. Being postmenopausal doesn’t give us a pass anymore.