“Nothing to be Done about Pain?” Not So.

I’ve talked about a couple of general topics prompted by reading the REVEAL research results: that lots of women aren’t aware of the effects of menopause on sexuality and that many of us aren’t talking about it. There’s one more topic that’s on my mind, because I hear about it every day in e-mails I receive from the “Ask Dr. Barb” link on our website.

It’s painful intercourse. In the study, 36 percent said that pain during sex made them stop having sex. That’s one issue. The other issue is that 59 percent of women who experience pain during sex still have intercourse on a regular basis. About three-quarters of those women have sex at least once a month, on average; a third have sex at least once a week.

The good news for the women among the 59 percent is that they recognize their sexuality as an important part of their selves and their relationships. The bad news, of course, is that it hurts. And more bad news is that not enough women realize that it doesn’t have to.

When midlife women talk about their sexuality, pain with sex is easily the most common physical complaint. This pain may feel superficial or deep. It may feel like burning or aching. It may happen only on initial penetration or only with deep thrusting.

The medical name for this is “dyspareunia" (dis-pu-ROO-nee-uh). It’s a tongue twister of a word, I know, but it comes from “dys” (as in dysfunctional) plus a Greek word that means “lying with”—so it’s as simple as “lying together doesn’t work.” It’s a general diagnosis that needs more investigation, because many things can cause the pain, and the pain can be experienced in a number of ways.

Another scary part of the research: A quarter of the women who experience painful intercourse thought that there was “nothing that could be done medically” to address their pain; I assure you that’s not true. There are solutions ranging from regular use of moisturizers and personal lubricants to overcome dryness to vaginal dilators to restore vaginal caliber (size and depth of the opening) to systemic or vaginal estrogen to maintain tissue health.

About a quarter also felt that their pain during sex was “an inappropriate conversation” to have with their health care provider; that’s not true, either.

Easy for me to say, I know, since I specialize in mid-life women’s health. Whoever your health care provider is, he or she will recognize the importance of sexuality to a full and healthy life. And if you don’t sense that, it’s worth it to find a sexually literate health care provider. Really.

Resolve to Speak Up!

I was struck by this sentence in a report on research with women aged 45 to 65 experiencing menopause: “As a generation, they have yet to develop a voice for this situation, and many remain silent rather than proactively seeing help.”

Really? We are the generation who, in high school, bought Our Bodies, Ourselves to better understand menstruation and sex. We pushed the boundaries to study science, go to medical school, become executives, compete for construction jobs, run our own businesses. We bought Marlo Thomas’s “Free to Be You and Me” for our kids.

But in my own experience as a physician, I see evidence that it’s true. When my practice included women of all ages, patients came in ready to talk in detail about physical symptoms—and emotional effects—related to pregnancy or fertility or uncooperative or uncomfortable periods. I don’t recall as many conversations about symptoms of menopause, especially as they related to sexuality.

In the last few years, since I’ve focused my practice on mid-life women, those who come to see me are ready to talk. This may have encouraged me to think we’ve made more progress than we have; this “REVEAL” (Revealing Vaginal Effecs at Mid-Life) study is a useful reality check. This research found that 41 percent of postmenopausal women had not talked to anyone about their sexual health in the previous year. Just over a third had talked to a health care provider; fewer—30 percent—had spoken to their partner or significant other.

The oldest women in the study—60 to 65—were least likely to have spoken to anyone at all. The younger women—45 to 49—were more likely to have spoken to someone: health care providers, partners, and then female friends.

Why does any of this matter? Consider the other findings of this research:

  • While almost all of the women surveyed were familiar with hot flashes as a symptom of menopause, fewer than half were aware that vulvar/vaginal pain was another symptom.
  • A quarter of those surveyed experienced pain during sex; most of those women still have sex—in spite of the discomfort—at least once a month.
  • The majority—80 percent—of the women who experienced pain during sex assumed it was a “normal part of getting older.”

That’s a whole lot of women who aren’t aware that sex can still be pleasurable and pain-free, even after menopause. And it’s a whole lot of women who won’t even broach the topic with their health care providers, because they assume that nothing can be done.

So! Clearly, it’s up to you! I imagine a whole lot of conversations between best women friends, women and their partners, sisters… and, for the sake of the next generation, between us and our daughters.

There are symptoms of menopause beyond hot flashes, night sweats, and mood swings. Decreasing hormone levels affect our vaginal and genital tissues, but they don’t spell the end of sexuality—or comfortable intercourse. There are things any woman can do to restore or preserve her sexual health, and we need to talk about them!

Sounds like a great resolution for 2011.

Q: I'm not interested in sex at all. Is it all in my head, as my husband says?

A declining interest in sex as we age is typical for women, but many face a couple of additional factors that are really big: 1) It is painful; and 2) the event itself may not be particularly engaging. Is it any wonder that there isn’t much motivation to participate?

If you have pain, you need to find a practitioner who can help solve that issue. There is almost always a solution for pain with intercourse. NAMS (The North American Menopause Society) is a good resource for finding a certified menopause practitioner if you feel your provider isn’t able to find a solution--or you're not comfortable discussing the issue with him or her.

The other issue is more difficult to address. After years, maybe decades, of a less-than-fulfilling sexual relationship, it is hard to reinvent, but most women would agree it is worth trying. For some menopausal women a great sexual relationship doesn’t even need to include vaginal penetration, but that takes a caring, nurturing partner.

Your partner needs to understand that romance and emotion are key to improving your libido--and you need to feel confident that you deserve that... because you do. For some women testosterone, in addition to that intimacy and foreplay, can make a remarkable difference in libido. Again, finding the right provider to investigate that option would be beneficial for you.

Some women have told me that visiting our site with their partners has been helpful. You might review the bonding behaviors together to start a conversation about what kind of foreplay and attention you need for a better opportunity for comfortable--even satisfying!--sex.

Your lack of interest is not in your head! I have yet to see a woman with pain with intercourse for which I couldn't find some cause and some solution options. Things to explore with a menopause care provider are atrophic vaginitis, vulvodynia, or vaginismus. Sometimes localized estrogen is required in addition to HRT to fully estrogenize the vagina.

There are solutions out there! Please explore them fully. Good luck, and don’t give up!

Q: Are mental fog and PMS-on-steroids related to perimenopause?

Oh, where do I begin? Perimenopause can be a pretty tough transition for many women. It is not only possible but probable that those symptoms are related. Patients with these complaints get a one-hour appointment in my practice to review the signs and symptoms that accompany this transition.

Riding it out is one option. Above all, make sure you optimize lifestyle, with exercise being probably the most important factor. Aerobic exercise of 45 minutes 5 days a week along with 60 minutes each week of strength training is a great goal to set.

I often recommend a book to patients: Dr. Robert Greene's Perfect Balance. It covers this transition quite well and reviews options in treatment including diet, exercise, and hormone alternatives. It was originally published in 2005, but is still one of the best I have seen.

Good luck! Things will get better!

Finding a Sexually Literate Doctor

None of us get through our adult lives without some questions about sexual functioning. And we go lots of places for answers, consulting family, friends, texts, the Internet, piecing together a quilt of inter-generational wisdom and ideas, sifting through marketing hype at the drugstore, trying to self-diagnose our situation and find the fastest-best-cheapest way to make it better.  Or sometimes we simply live without answers to our questions, wondering and miserable.

This is a time-consuming and inexact way to learn that can lead to some uncomfortably misguided behaviors (Yogurt douche, anyone?).

Is there a better way? We think there is: You deserve a Sexually Literate Doctor.

Surveys tell us only 14 percent of men and women between ages of 40 and 80 have EVER discussed sexuality or sexual health with their doctors.  I attended a women's sexual health conference this month, and out of 100 people in the audience, only one had EVER been asked by her doctor about sex.

That is, women who have worked for years with their gynecologist to bring their babies into the world don’t discuss sex with them. When discussing menopause symptoms and treatment, sex doesn’t come up. Women are more comfortable ignoring the sexual changes or treating  sexual difficulties from drugstore or pantry shelves than through interaction with their health care providers.

And there’s good reason. For most of our lives, our physicians couldn’t help us. Most of them simply didn’t know how.

Until very recently, not many doctors had the training to discuss female sexual function, and particularly post-menopausal sexual function. As recently as 10 years ago it was common for a physician to receive just an hour or two of training in female sexual function during their entire residency.

That's why I started MiddlesexMD!  Sexual literacy among physicians is getting better every day, but until thorough sexual health training is common in our medical schools, we still have to look around a bit to find a Sexually Literate Doctor who can answer our questions when we need help.