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Menopause and sex

Lankenau Medical Center July 9, 2011 Menopause and You By Kara Nakisbendi, MD

Women are sexual beings throughout their lifespan. Menopause should not be seen as an end to sexuality or sensuality. While there are some effects of menopause, sexuality is complex and can be affected by medications, stress, illness and our attitude towards it. Dr. Kara Nakisbendi nicely outlines some of the issues surrounding sexuality and menopause. There is sex after menopause! – Beverly Vaughn, MD, Medical Coordinator, Menopause and You Program

There are many myths and misconceptions about menopause that can make women fearful of this transition. One of the greatest myths is that menopause will cause women to lose interest in sex and that they should expect their sex lives to dwindle. While many physical and psychological changes that occur during menopause can affect one’s sexuality, this does not mean a woman can’t maintain or attain a satisfying sex life. In fact, there are many positive aspects to menopause that may help women let go of fears and fully embrace their sexuality. Sometimes we have to readjust our thinking and broaden our definitions of sex in order to attain the level of intimacy we desire.

Physical and emotional related causes

Many physical and emotional changes occur in the perimenopausal period that can affect one’s libido or sexual response. Erratic menstrual cycles can leave women feeling unsettled as they may rely on their normal cycle for reassurance that they are not pregnant. The fear of pregnancy can make it difficult to fully enjoy sexual intimacy. In addition to changes in their bleeding, women may begin to notice hot flashes, night sweats, vaginal dryness, memory lapses and even heart palpitations. These symptoms are typically worse as a woman approaches her menstrual period. Understandably, these symptoms may leave women feeling exhausted and short fused. A woman's desire in sex may be diminished as a result. Some women, though, may experience an increase in libido during this time because they experience surges in their estrogen levels. Sometimes this increased libido can interfere with daily activities.

It is important to realize that every woman’s experience is different. The variations in how women experience menopause is so vast that the fear of the unknown can be greater than the symptoms themselves. It is impossible to predict how a woman will transition through menopause.

In dealing with the loss of sexual functioning, it is essential that each woman’s situation be fully assessed. While the loss of estrogen and the decline of androgens can affect sexuality, so can chronic illness, medications and emotional conflicts. A health care provider can help determine the etiology of the loss of sexual functioning through a careful history taking.

Illnesses, such as coronary artery disease or diabetes, and antidepressant medications can all affect libido and sexual response. Many women are prescribed these medications during the menopausal period, making it difficult to separate whether the lack of hormones or the medications are the cause of the dysfunction. While stopping the medications is not usually an option, discussing alternatives may be the answer. Many of the antidepressants such as Prozac®, Paxil® or Zoloft® may cause delayed sexual response and anorgasmia. Sometimes substituting a medication with a lower sexual side effect profile, like Wellbutrin®, may ameliorate these symptoms.

Some studies show that adding Viagra® may alleviate some of the sexual side effects of antidepressants. It is also important to realize that a depressed person will already be experiencing a decreased libido, and by treating the depression she may regain her interest in sex no matter which antidepressant she is taking. Everyone reacts differently, so patients should not assume that they will experience a loss of sexual functioning while on these medications.

Sexual functioning hormones

Androgens and estrogen are both important hormones for sexual functioning. Androgens in the form of testosterone and dehydroepiandrosterone sulfate, or DHEAS, are present in women, albeit in much smaller quantities than in men. Androgen levels start to decline in a woman’s thirties and forties. By the time menopause approaches, these levels have already significantly decreased but then remain at this lower level. Androgen insufficiency syndrome has been described in some postmenopausal women or women who have undergone a surgical menopause as a loss of libido, sexual receptivity and pleasure. There are saddened or depressed moods and low energy. Testosterone levels in women experiencing androgen insufficiency syndrome are found to be much lower than the average in menopausal women. Testosterone replacement in very small doses in the form of tablets, patches or creams can ameliorate these symptoms. Patients should be aware that the treatment of sexual dysfunction with testosterone has not been fully studied. While side effects can occur, the doses used are usually very small. Liver function tests may needed in certain situations. The drop in levels of estrogen during menopause is significant and alone can cause decreased libido, decreased sensation of the genitals and delayed sexual response and orgasm. Women may find it takes them much longer to attain orgasm. Sometimes the use of a vibrator or the Eros-clitoral therapy device can assist with this by providing stronger stimulation to the genital area. It is also important to feed one’s mind with sexually stimulating fantasies through either reading or viewing erotic materials.


Some natural remedies are thought to be beneficial such as L-Arginine, Yohimbine and DHEA. One must be cautious with any herbal remedy as it may interfere with other medications or affect a medical condition. This should be discussed with your physician. Pharmacologic treatments available include estrogen and progesterone replacement. Even though there have been studies demonstrating risks with hormone replacement therapy, it is still a viable option for some individuals as long as all of the risks and benefits are addressed. Viagra, which has been studied extensively in men, may help some women as well by increasing the blood supply to the vagina and the clitoris.

Eliminating vaginal dryness

Vaginal dryness is an important symptom to address because it typically does not resolve and with time may get worse. Due to the lack of estrogen, the walls of the vagina become thinner or atrophic. The glands of the vagina become atrophic as well, causing a decrease in lubrication. This may result in painful intercourse, or dyspareunia. Dyspareunia alone can cause women to avoid any sexual contact for fear of pain.

Over time, this may result in a lack of desire, and a woman may settle for no sexual intimacy. The good news is that it is treatable! Local vaginal therapy with estrogen and/or vaginal lubricants usually resolves this issue. Sometimes vaginal dilators are necessary to help treat vaginismus, the involuntary contraction of the vaginal muscles, which can occur after a women has experienced vaginal pain.

Psychological aspects

Depending on the messages a woman has received in her earlier years and on the relationships she has experienced, many factors will play into whether she experiences sexual fulfillment through her menopausal years. Perhaps the greatest indicator of how sex will be after menopause is to look at how it was before menopause. While illness, life stresses, medications, and the loss of a partner can deeply affect a woman’s sexuality, it doesn’t mean it no longer exists. Some women first realize in their sixties that they have never had an orgasm and decide it is time to change that. Some women continue to enjoy using their vibrators into their seventies! What needs to change is our narrow definition of sex. If we can expand our minds to include our whole body as a sexual organ, we will experience greater sexual satisfaction. We should not view orgasm or vaginal penetration, while satisfying, as the only goal. When we do that, we limit ourselves and miss out on all the possibilities.

Whether a woman is single or not, the menopause can be a time to explore with or without a partner all those things she didn’t have time to look into before. For those women with a partner, good communication and a sense of humor are the key elements to a satisfying sexual relationship. Constantly sharing desires and needs can help a couple make a transition like menopause easier. A satisfying sexual relationship is a work in progress. While attaining orgasm may become more difficult as we age, we might have more fun and laughs along the way.

The best advice for women transitioning through menopause is to address your fears, educate yourself and find people with whom you can share your stories. If you are experiencing problems, find a physician who will address all of your needs and can help you through this process. There are many options when dealing with the loss of sexual functioning. Don’t be afraid to ask about them.

This article is part of Menopause and You, a web-based program sponsored by Women’s Health Source. It is intended as an information resource providing guidelines for women. As always, check with your own health care provider with your specific concerns and questions.

To speak with our nurse counselor, call 1.888.876.8764 or email whs@mlhs.org.

Membership on the medical staff of Main Line Health hospitals does not constitute an employment or agency relationship.