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Do women lose their sexuality after menopause?
Do women lose their sexuality after menopause? The quick answer is,
"no". Women are sexual beings throughout their life. However, this
response is too simplistic. During menopause, women's bodies undergo a series of
biological changes which have social implications within the context of North
American culture. In order to fully acknowledge this complexities of this
question, the definition of menopause, including medical treatments aimed at
mitigating its less desirable aspects, and the psychosocial implications of
menopause, itself, must be explored.
Menopause & Social Implications
Menopause refers to the time when a woman ceases menstruating. Menopause
marks the ending of a woman's reproductive cycle in a manner analogous to the
way that puberty marks the beginning of a woman's reproductive cycle. Beginning
around the age of thirty-five, many women begin to experience aberrations in
their reproductive cycles, a decline in ovulation, and an increased frequency of
menstruation, which lasts for fewer days. These changes are part of the natural
aging cycle. However, some women experience none of these changes (20%) until
their menstruation ends altogether (Clay, 1981). With age, all women's ovaries
begin to react less efficiently to the Lutineizing Hormone (LH) and Follicle
Stimulating Hormone (FSH), which originate in the pituitary gland, eventually
leading to the complete cessation of menstruation. Menopause refers to a
'climacteric' fifteen-year period, encompassing the "gradual process of
ovarian failure which normally precedes and extends beyond the last menses and
within which menopause is only an event" (Ritz, 1981).
The process of menopause can be rapid or gradual. Rapid menopause is usually
iatrogenic; that is when women may have experienced chemotherapy/radiation
related ovarian damage or undergone bilateral oophorectomy (removal of both
ovaries), initiating premature menopause (Devprabu & Carpenter, 1997). For
women who experience gradual peri-menopause, the exact onset of menstrual
discontinuation varies from person to person, often beginning somewhere between
age 35-45. The exact beginning date of menopause is typically determined as one
year from the date of the woman's last menstruation.
During the reproductive years, a woman's ovaries play a crucial role in
hormonal balance, in that they are responsible for 90% of overall estrogen
production (estrogen synthesis) and approximately 50% of daily testosterone
production (Devprabu & Carpenter, 1997). The remaining 10% of estrogen
synthesis is produced by the adrenal glands and fat cells, which convert
pre-cursors of estrogen into estrogen (Robboy, 1998). Similarly, the remaining
production of testosterone is produced by the adrenal glands (Devprabu &
Carpenter, 1997). This overall decrease in hormonal production, which stems from
changes in the hypothalamus, the neural center of the brain, is responsible for
the many of physical changes experienced by peri and post-menopausal women
(Robboy, 1998). Menopause is typically confirmed through a blood test that
confirms the decline in female hormonal levels.
The above definition of menopause, which talks about the 'failure' of the
ovaries stemming from the hypothalamus, lends itself to the perception that
women's bodies during and after menopause are in a state of 'decay'. This may
account for the uncertainty many people have regarding the loss of feminine
sexuality following menopause. Given this assumption, such questions naturally
follow.
If women are in the process of decaying, what is left of a woman's sexuality?
Rest assured, women do not lose their sexuality after menopause. In fact women,
like their male counterparts, are sexual beings throughout their lives, with
both genders experiencing a decrease in estrogen levels, which has been directly
linked with sexual functioning. Like puberty, menopause is a period of
transition, and is best understood as a part of normal developmental evolution.
Within this framework, the expression of sexuality may change, as all humans,
themselves, do with age, but it is not a matter of decay or growth, it simply
is.
Historically, the 'diagnosis' of menopause has been held responsible for
every mood change or unexplained feeling that women experienced throughout the
climacteric 15 year period. Menopause, representing a state of decay, often
required 'treatment' to protect women from their natural biological changes.
Such interventions have included medication, verbal therapy, hormonal
replacement therapy, or surgery. In fact, in the first half of the 20th century,
according to the DSM II, women were thought to suffer from a post-menopausal
depression, classified as 'Involutional Melancholia'. The standard treatment of
this "mental disorder" often required hospitalization. The association
between hospitalization and menopause led many women to fear that the cessation
of menstruation might precipitate lunacy. This "disorder" was
eventually recognized as an inappropriate category and was subsequently omitted
from the DSM III. However, the myth that menopause causes insanity persists (Weissman,
1979).
In stark contrast to the societal values, which the diagnosis 'Involutional
Melancholia' represent, menopause in actuality may be a positive occurrence.
According to a study cited by NAMS conducted by the Gallup Organization, eight
out of ten women viewed menopause as a positive event. This survey, consisted of
750 American women between the ages of 45 and 60, 80 % of whom reported feeling
relief at no longer have to deal with the hassles of menstruation, for the first
time since menarche. They further reported no longer having to experience
monthly cramps, low back pain, rapid hormonal changes, blood-stained clothes, or
worry about carrying pads/tampons. Overall, the women viewed aging and menopause
as a positive event (NAMS, 1998).
Furthermore, post-menopausal women report that they are able to engage in all
forms of sexual pleasuring without harboring a fear of pregnancy, nor do they
need to concern themselves with birth control methods or their side effects. For
example, the side effects of oral contraceptives, one of the most popular forms
of birth control, are weight gain; mood swings; remembering to take the pill at
a certain time; and the financial burden. Thus, without the fear of pregnancy,
many post-menopausal women find themselves more able to enjoy their sexuality
and feel are freer to act impulsively.
Common indications of menopause
Common indications of menopause that women in the United States report and
their home remedies
Hot flashes, are sudden, uncontrollable fluctuations of body temperatures,
similar to generalized flushes. They often begin with a tingling sensation,
which rise to the mid-body, causing reddened skin, dizziness, rapid heartbeat,
chills, and sweating. Hot flashes can occur at any time of day and in any
location. However, they most often occur during sleep. Hot flashes, on average,
last somewhere between 30 seconds to five minutes. This effects 75-80% of
per-menopausal women in the United States (Bates, 1981), although the degree of
impact varies. Only a small percentage of women report that hot flashes impair
normal functioning. However, hot flashes can lead to frequent sleep
disturbances, causing exhausting, chills and discomfort, all of which can make
women feel less comfortable or embarrassed about their bodies.
Hot flashes occur due to changes in hypothalamus functioning (Bates, 1981).
In addition, other mechanisms, not yet recognized, may also be responsible for
the irregular dilation and constriction of blood vessels (Chen, 1993). Estrogen
may be also play a role in hot flashes because they must be absent when a hot
flash occurs. Hot flashes seem to be the body's way of re-signaling the
pituitary gland to respond to the decrease in endogenous estrogen.
Interestingly, five years after the onset of menopause, 60% of women continue to
experience hot flashes (Greendale & Judd, 1993). Yet, regardless of
treatment, (including no treatment) hot flashes in most women eventually
disappear.
To reduce discomfort that women may experience as a result of hot flashes,
women can do several things. Increased level of exercise accelerates the
conversion process of androstenadione from body fat into a type of estrogen,
estrone (Robboy, 1998). Secondly, adequate fluids, eating a healthy diet with
sufficient calcium (NAMS) Vitamins B and C, and decreasing the intake of spicy
foods, hot beverages, tea, and alcohol decreases the stress placed on the
adrenal glands, allowing them to function more efficiently. Thirdly, taking cold
showers, keeping the room cool, and avoiding tension may lower the frequency of
hot flashes.
Mood Swings and Depression tend to be caused by constant fluctuations of
hormonal levels and/or mid-life events. In a study which examined mood
fluctuations for women who were using the pill, Paige (1971), found that changes
in hormonal levels impact mood (Paige, 1971). Concomitantly, between the ages of
40-60, children are often leaving home, which can leave women grappling with
role changes, the possibility of marital strife and/or divorce, in addition to
other mid-life stresses such as professional changes, retirement, and even the
death of a parent. Therefore, regardless of menopausal status, developmental
stressors may make women more prone to mood swings and depression. When a woman
experiences depression, this, in and of itself, can negatively impact the way in
which she relates to both herself and others sexually. Moreover, depression
tends to diminish awareness of positive sensations experienced by the depressed
person. In order to effectively cope with the mood swings and depression, women
should be encouraged to talk openly with others about feelings. In fact,
participating in a support group women experiencing similar issues may not only
be informative (recommendations of doctors, treatments, experiences…) but also
normalizing. Women need to gain access to information and also to connect with
others in order to subjectively experience that they are not alone in the
mid-life feminine process.
Vaginal Atrophy refers to the shrinking, thinning, drying, and decreased
elasticity of the vaginal mucosa caused by prolonged deficiency of estrogen
(Masters, Johnson, & Kolodny, 1994). Estrogen is, in part, responsible for
the lubrication in the vagina. A decrease in lubrication may cause the vaginal
walls to more readily become irritated, tear and/or become infected. One common
manner in which women deal with these changes is to ignore the pain, while
continuing to engage in the very sexual behaviors which lead to discomfort. Over
time, this strategy may lead women to associate pain with penile-vaginal
intercourse and thus become avoidant of these behaviors. This avoidance behavior
may result in either the woman viewing herself as asexual or in others viewing
her this way. In reality, the change in female lubrication is more indicative
that her sexual partner may need to adjust. She may benefit from prolonged
stimulation and/or the use of lubrication. In this regard, there are several
options. Women may want to use an estrogen replacement cream, which helps women
to self-lubricate. Second, women may purchase over-the-counter lubrications,
such as Astroglide or K-Y Jelly or Replens, a nonprescription, non-hormonal
lubricant that worked as well as estrogen cream in a 1994 study (Dranov, 1997).
Lastly, according to Masters and Johnson, (1994) one of the best ways to
increase lubrication is by engagement in frequent sexual pleasuring. Moreover,
because lack of sexual activity may actually contribute to vaginal atrophy, it
is important to keep all the pelvic and perioneal muscle groups in active use.
In addition to engaging in sexual pleasuring, women may benefit from
strengthening her PC muscle which plays an important role in orgasm. This can be
done through the use Kegel exercises.
Menopause emotionally or physically disables only a small percentage of the
female population (10-15%). Similarly, 10-15% of all women exhibit no
symptomology at all. However, most women experience mild symptoms due to
fluctuations in hormonal levels (Robboy, 1998). Of these, only a small
percentage affected seek medical treatment (Greendale & Judd, 1993). Prior
to discussing medical interventions used to reduce discomfort caused by the
onset of menopause, there is a fundamental question that must be addressed: Do
hormonal treatments improve the quality of women's lives? And, if so, to what
extent? The issue of whether women should be advised to embark upon long term
hormonal treatment is controversial. Medical arguments rely heavily upon the
interpretation of research 'results'. The interpretation of these 'results' are
subjective not only because of how scientific information is understood, but
also because of concepts related to what constitutes 'disease' versus the
'natural' aging process.
Hormone replacement therapy seems to indicate that if declining hormones are
replaced than she will resume her "natural state". Thus, the question
emerges, even if women are able to live longer, reproduce, and decrease certain
medical risks, won't old age naturally increase other risks? Furthermore, if a
woman embarks upon one of these forms of medical treatment, are the benefits
worth the financial burdens and restraints engendered by depending upon medical
supervision? Perhaps the low compliance rate (approximately 50%) speaks directly
to this issue.
Estrogen Replacement Therapy (ERT)
Estrogen replacement therapy made it's debut in the 1940s as a treatment to
reduce the negative impacts of menopause. By 1992, doctors had prescribed ERT to
36.4 million women (Wysowski, Golden, & Burke, 1995). Part of the rise in
popularity of ERT as a form of treatment to cure vaginal dryness, cancer, heart
trouble, and depression followed a huge advertising campaign in the 1970s to
increase the popularity of the drug Premarin ® (Seaman & Seaman, 1991).
However, the numbers of women using ERT may be misleading. According to Ravikar,
an observational study found that 20-30% of women who are prescribed ERT opt not
to fill their prescriptions.
Furthermore, within 9 months of use, an additional 20% stop using this form
of treatment. Therefore, there is a 40-50% non - compliance rate (Ravnikar,
1987). Issues of non-compliance have improved due to the invention of
transdermal E sub 2, which is an estrogen, in the form of a patch that is placed
on a woman's arm. However, this patch must be replaced daily, which is
problematic in terms of compliance issues. In order address this, attempts are
being made to design a patch that needs replacement once a week. The patch
currently used specifically relieves menopausal symptoms, decreases vaginal
atrophy, and forestalls osteoporosis (Jewelewicz, 1997).
ERT is often recommended to menopausal women as a way to prevent the 'decay'
of women. ERT has been found to decrease the rate of heart disease, slow the
rate of osteoporosis, and improve cognition and slow its age-related decline .
In 1991, a longitudinal study was conducted which tracked the rate of women
taking ERT and the rate of heart disease over ten years. It was found that ERT
was associated with a reduced rate of heart disease. However, the results may be
problematic due to the design of the study. Not only were the groups of women
who participated in the study not matched, but the study was designed 10 years
after the use of the ERT (Stampher et al, 1991).
ERT may be important to slowing the rate of osteoporosis development because
estrogen is an important factor in bone growth. According to Lobo, ERT also
improves cognition (Lobo, 1995). To determine the effects of ERT on the
cognitive capacities of postmenopausal women, 70 women who used estrogen were
compared with 140 women who had never used estrogen to see who would perform
better on cognition tests. The results of this study demonstrated an association
between ERT and improved cognition (Schmidt et al., 1996).
Drawbacks to ERT may be dose and duration dependent (Holst, 1983). The known
side effects of ERT consist of an increased risk of endometrial and breast
cancers and similar rates of osteoporosis for males and females beyond age 80
[Boston Collaborative Drug Surveillance Program, 1974 #20. ERT masks the natural
evolution of the body therefore, decreasing the natural transitions.
Furthermore, with the invention of ERT, women, more so than ever, must rely upon
chemicals for their health. The long-term implication for such women is that
they must always be under the care of a physician which requires not only
frequent monitoring, but is expensive. For women concerned about post-menopausal
sexual functioning, ERT may be a subject worthy of exploration. As mentioned
earlier, ERT directly improves vaginal lubrication and does not interfere with
the newly found freedoms from menstruation and fear of pregnancy associated with
menopause. However, while ERT may 'cure' some of the problems associated with
menopause, ERT's side effects, such as cancer of the uterus, may outweigh the
benefits. Therefore, it is recommended that women avail themselves of this form
of medication for as short of a time span as possible.
Hormonal Replacement Therapy (HRT)
Hormonal Replacement Therapy (HRT) reduces the risk of cancer of the uterus,
because of the combination of progesterone and estrogen (Grady, Gebretsadik,
Kerlikowske, Ernster, & Petitti, 1995). As in the natural menstrual cycle,
progesterone acts as a stimulant to the growth of endometrium, which leads to
its eventual removal, or sloughing off during menses. With ERT, there is no
progesterone to counterbalance the effects of estrogen, which chronically
stimulates the endometrium which has no way of sloughing off, thus leading to
endometrial cancer. This imbalance is mitigated with the inclusion of
progesterone in HRT. Since ERT's debut in the 1940s, research has focused on how
to make the treatment safer. Whereas, in the 1940s, estrogens were given to
women at a much higher level, 1.25 milligrams, by the 1980's, the levels were
reduced to 0.6 milligrams, with researchers now testing the degree of
effectiveness at 0.3miligrams (Robboy, 1998).
HRT is primarily recommended to slow the rate of osteoporosis (Felson, 1993),
heart disease (Sullivan et al.,1990), and to decrease frequency of hot flashes
and night sweats (Branswell, 1998). In one study, it was found that after 15
years use of HRT, the death rate of women was decreased by 40% (Henderson,
Paganini-Hill, & Ross, 1991). HRT is known to prolong the life of
post-menopausal women primarily because of a reduction in cardiovascular
disease, specifically coronary heart disease (Lobo, 1995). In addition, HRT is
often recommended to women who experience surgical menopause due to a
hysterectomy / oophorectomy for non-cancerous conditions (Langenber, Kjerulff,
& Stolley, 1997). HRT has benefits over ERT, the addition of progesterone to
the last ten days of the cycle, eliminates the increase risk of breast cancer
(Martin & Freedman, 1993) from the increased usage of estrogen (Colditz et
al, 1990). While both HRT & ERT decreases certain health risks, they
increase others. However, on average, women tend to have more complaints about
the side effects of HRT. This includes "spotting" several days each
month, which can be a source of frustration for women (Dranov, 1997) and
engorged breasts which can be very painful (Robboy, 1998).
The estrogen within HRT, like ERT, acts to increase vaginal lubrication,
strengthen bones, and decrease blood pressure. Some people even believe that HRT
may increase a woman's sexual desire. One of the primary advantages (and
disadvantages, depending) of using both estrogen and progesterone is that it
stimulates ovulation. This means that women can prolong the reproductive cycle
and, with the use of medical technology, (oocyte donation or frozen eggs)
continue to bear children . In fact, it has been reported that a 63-year old
woman was able to conceive and bring a healthy child to term. To date, there
have been at least 100 children born to postmenopausal women through oocyte
donation (Eisenberg & Schenker, 1997).
The idea of birthing children beyond the restrictions of the natural
reproductive cycle, alters previous notions of 'menopause'. Menopause is no
longer a determinant of the stop-point for the reproductive life-cycle. This
raises a number of ethical issues. Should a woman at any age be encouraged or
even allowed to reproduce? What does this mean in terms of a woman's right to
control her own body? The basis of oocyte donation is a fundamental right in the
United States, based in part on who has the financial resources to afford it. Is
this the same for women who opt to use HRT as a treatment modality? Does society
have a greater social obligation to pre-menopausal women trying to conceive than
to post-menopausal women? What level of medical technology is considered
appropriate? Have these questions evolved from the debate that currently rages
around abortion? What are the biomedical-ethical implications? What are the
rights of the child? Mother? Father? What are the social implications to the
community at large? What are the political issues motivating the rhetoric?
Conclusion to Sex & Menopause
All this seems to indicate that menopause, with the use of new medical
technology may have little to no impact on women's long term sexual and
reproductive functioning. Over the years, menopausal women have been viewed as
going 'crazy' and needing hospitalization, to full functioning women with
successful careers, active sexual lives, to having the post-menopausal
capability of birthing children. Only politics and medical technology have
changed.
Therefore, for women who are trying to navigate menopause the best
recommendation is to educate themselves about their bodies. This means reading
books and literature, speaking with friends and family, joining support groups
either face-to-face or through the web, and conferring in an informed manner
with primary care health providers. Make sure that your health care does not
have a bias towards one particular drug, and is not afraid to exhaust all the
least invasive methods first. Above all, share women should share concerns with
their partners. Women, like men, are sexual beings throughout their lives. The
most important aspect is self-education and communication with one another.
All tips written by Alex Robboy, LSW
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