Perimenopause and Menopause Care

The loss of estrogen and testosterone leading up to and following menopause can lead to changes in a woman's body and sexual drive. Menopausal and postmenopausal women may notice that they're not as easily aroused, and they may be less sensitive to touch. That can lead to less interest in sex. Satisfying sex depends on several things: presence of desire, arousal, absence of pain, and an ability to reach orgasm. After menopause, libido declines, and changes in our bodies can make it difficulty becoming aroused, pain during intercourse, and inability to achieve orgasm. Also, lower levels of estrogen can cause a drop in blood supply to the vagina. That can affect vaginal lubrication, causing the vagina to be too dry for comfortable sex. It's little wonder that many women become dissatisfied with sex, and some avoid intimacy entirely.

Other factors that may influence a woman's level of interest in sex during menopause and after include:

-Bladder control problems

-Sleep disturbances

-Depression or anxiety

-Stress

-Medications

-Health concerns

Lack of desire is a major issue and one for which there is no quick fix for women.  That doesn't mean there aren't other solutions for women. The key is identifying the reasons you might have lost interest in sex and designing a treatment to address them. Among the most common contributors to lost libido are these:

Declining hormone levels. In women, both estrogen and testosterone can contribute to libido. Estrogen is manufactured by the ovaries and in body tissues; testosterone, by the ovaries and adrenal glands. While estrogen levels drop sharply at menopause, testosterone levels decline slowly and steadily with age. Woman whose ovaries are removed before menopause often experience a dramatic loss of libido. Some studies have shown that systemic hormone replacement therapy can improve libido and sexual responsiveness in women, although it might take three to six months before it's fully effective. Moreover, the health risks might outweigh the benefits for most older women.

Depression. Depression dampens desire and is increasingly common in midlife. Taking a selective serotonin reuptake inhibitor (SSRI) like fluoxetine (Prozac) or paroxetine (Paxil) can be effective for depression, but it can also reduce your sexual responsiveness. Switching to bupropion (Wellbutrin) helps some women, although it may not completely restore lost libido.

Medication. Drugs for high blood pressure can also affect desire. Since there are many options available, your physician can help you find one that keeps your blood pressure down without lowering your libido.

Physical illness. Undergoing treatment for cancer or another serious illness can diminish interest in sex.

Stress and anxiety. Job pressures, family responsibilities, lack of privacy, and worries about children or aging parents can render sex a low priority.

Relationship strains. If you feel yourself growing away or disconnected from your partner, you aren't as likely to be interested in sex with him or her.

Both arousal and orgasm depend on a complex array of psychological and physical factors. Issues that reduce libido can also affect arousal and orgasm. In addition, when blood flow to the genitals and pelvis is diminished or nerves are damaged, it can be difficult to achieve either. Identifying and addressing lifestyle factors may increase your sexual response. These are the most common physical factors impeding arousal and orgasm:

Alcohol. Although a glass of wine might enhance your libido, heavy drinking can make it difficult to achieve orgasm.

Health conditions. Diseases that affect blood flow and nerve function, including diabetes, kidney disease, heart disease, and multiple sclerosis, can reduce sexual responsiveness.

Medication. Drugs to lower blood pressure can delay or prevent orgasm. Antidepressants, particularly SSRIs, can also impede orgasm.

Clinical trials have demonstrated that the following may be helpful in stimulating arousal and orgasm:

A massage oil that creates a sensation of warmth throughout the genital area, to increased desire, arousal, and satisfaction in 70% of the women enrolled in clinical trials required for FDA approval. 

A Clitoral Therapy Device that increases genital blood flow by applying a gentle vacuum to the clitoris. In one clinical trial, 90% of women reported an increase in sensation, and 80% reported increased sexual satisfaction.

Vibrators. There is no dearth of these devices, none of which requires FDA approval, so there aren't a lot of studies demonstrating their effectiveness. In one of the few clinical trials—a 2016 study of 70 women who had difficulty becoming aroused or reaching orgasm—two-thirds of participants reported increased vaginal lubrication, orgasm, and genital sensation after using a vibrator for three months.

Dyspareunia—pain during intercourse—affects about half of postmenopausal women and is one of the most common reasons women shy away from sex. "If doing something hurts, you're going to stop doing it," Dr. Green says. Pain may be more pronounced during entry or deep penetration and is likely to stem from one of the following:

Vaginal atrophy. When estrogen plummets following menopause, the vaginal lining thins, vaginal walls become less elastic, and lubrication diminishes. These changes can result in vaginal dryness, burning, or itching that is exacerbated during entry. Topical estrogen—as a cream, a suppository, or a ring that releases the hormone over three months—can help plump up vaginal tissues and aid lubrication.

Vaginal moisturizers can also be used on a more regular basis to maintain moisture in the vagina.

During and after menopause, vaginal dryness can be treated with water-soluble lubricants.

Water-based lubricants and longer-lasting silicone-based lubricants can also make penetration less painful.

Urogenital inflammation. Vaginal and urinary tract infections and skin conditions like eczema, psoriasis, lichen sclerosus, and lichen planus may cause entry pain and can be treated with antibiotics or topical steroid creams.

Chronic conditions and treatments. Treating underlying medical conditions like back pain, hip problems, uterine prolapse, and irritable bowel syndrome can relieve pain. When pain with deep penetration is due to radiation, chemotherapy, or surgical scarring, physical therapy—in the form of exercises and massage to relax and stretch tissues in the pelvic area—can also be helpful. However, it may take several weeks or months of physical therapy to substantially alleviate the problem.  You may also incorporate vaginal dilators into your physical therapy routine to help gently and gradually stretch the vaginal tissue.

Remember that communication with one's partner is the foundation of a healthy sexual relationship. To improve your physical intimacy, try these tips:

-Be honest. Don't try to fake it if your libido has dropped. Let your partner know when sex is painful.
-Compromise. If one of you wants to have sex more frequently than the other, you should try to find a middle ground.
-Experiment: If intercourse is painful, the two of you might try new positions and techniques that may be more comfortable. It may help to remember that vaginal intercourse isn't the only option. Genital stimulation and oral sex may provide as much satisfaction as you need.

-Consider experimenting with erotic videos or books, masturbation, and changes to sexual routines.

-Use distraction techniques to boost relaxation and ease anxiety. These can include erotic or non-erotic fantasies, exercises with sex, and music, videos, or television.

-Have fun with foreplay, such as sensual massage or oral sex. These activities can make you feel more comfortable and improve communication between you and your partner.

-Minimize any pain you might have by using sexual positions that allow you to control the depth of penetration. You may also want to take a warm bath before sex to help you relax, and use vaginal lubricants to help ease pain caused by friction.