What is the menopause?
The menopause is when a woman’s periods stop permanently because the ovaries no longer produce oestrogen or release eggs. This may occur naturally or as a result of the ovaries being removed by surgery, or damaged by chemotherapy or radiation. A natural menopause is usually confirmed by a year of no periods.
The time before your last period, when your hormone levels are falling, is known as the ‘perimenopause’. This usually starts in the mid to late 40’s and lasts about 4 years. In the UK, the average age at which the menopause occurs naturally is 51, and it happens about 2 years earlier in smokers. If it happens before the age of 40, it is considered premature.
The start of the perimenopause is marked by changes in the menstrual cycle. These include changes the amount of time between bleeds (which may shorten or lengthen) and changes in the amount and duration of bleeding. Then periods start to be missed altogether.
Women in the perimenopause report a variety of different symptoms. These include hot flushes, night sweats, difficulty sleeping, tiredness, mood changes, memory loss, joint and muscle pain, breast tenderness, urinary incontinence, vaginal dryness, a lack of interest in sex, headache and weight gain. However, not all of these symptoms appear to be specifically related to the hormonal changes that occur during the perimenopause. For example, trouble sleeping may be due to bothersome hot flushes and night sweats, memory loss and tiredness may be due to trouble sleeping or frequent hot flushes, and a lack of interest in sex may be due vaginal dryness causing pain during sex.
Menopause symptoms usually continue for around 4 years after the last menstrual period, but in about 10% of women, they may last up to 12 years. However, every woman experiences the menopause differently. Your symptoms may be severe and distressing, or mild and short-lived, or you may have no symptoms at all. Women who have had a hysterectomy (surgical removal of the uterus/womb) can still experience menopause symptoms.
How does it affect the vagina?
Reduced oestrogen levels may cause a number of changes in the vagina, including thinning of the walls, reduced elasticity, reduced blood flow and reduced lubrication (‘wetness’). Changes in vaginal fluid promote the growth of ‘bad’ bacteria and increase the risk of both vaginal and urinary tract infections.
Vaginal symptoms as a result of these changes may include dryness, itching, discomfort and pain during or after sex (see our factsheet ‘Pain during/after sex’ for more information on this). However, these symptoms may not appear until many years after the last menstrual period.
In women, testosterone is also produced in the ovaries and it is linked to female sexual function. A lack of sexual desire (also known as a lack of ‘sex drive’ or ‘libido’) may be associated with a drop in testosterone levels. A lack of sexual desire may in turn cause a lack of sexual arousal (not feeling ‘turned on’), which may include a lack of vaginal lubrication. A lack of testosterone may be more noticeable in women who have had their ovaries removed by surgery (oo-phorectomy), as their testosterone levels suddenly fall.
Of the vaginal symptoms that occur with the menopause, a lack of lubrication during sex is often the first to be noticed. Vaginal lubrication plays an important role during sex and women are usually expected to produce a moderate amount. Women have reported that they prefer sexual intercourse to feel ‘wetter’, feel more able to orgasm when sex is wetter, and think that their partner prefers sex that feels more wet than dry.
In an American study, vaginal discomfort related to menopausal changes caused 58% of women to avoid sex, with 59% finding sex painful and 64% reporting a loss of libido. Around 30% of women and men in the study said vaginal discomfort was the reason they stopped having sex altogether.
Research conducted in the United States and Europe has shown that moderate to severe vaginal symptoms may reduce a woman’s quality of life as much as serious conditions like arthritis, asthma, chronic lung disease and irritable bowel syndrome.
However, many women don’t seek help for vaginal symptoms. And unlike the other menopause symptoms, which tend to reduce in the years following the last period,
Vaginal dryness is likely to get worse if it is not treated.
How is it diagnosed?
Your doctor can probably tell if you are perimenopausal or menopausal depending on your age, menstrual cycle and symptoms. Diagnosis may be more difficult if you are taking hormonal treatments (e.g. to treat heavy periods).
They might need to examine you. This may include examination of your external genitals or ‘vulva’, which includes the opening of the vagina, the fleshy lips surrounding this and the clitoris. They may also examine the inside of your vagina with gloved fingers and/or a speculum (a plastic instrument which is inserted into the vagina and gently widened to allow better visual examination).
Your doctor may want to do a ‘swab’ or urine test to check for infection. A ‘swab’ is where a kind of cotton bud on a long stick is rolled over the skin on the inside or the outside of the vagina to collect discharge or skin cells and then sent away to the laboratory to see what bacteria are present. They may also want do blood tests to check your hormones/general health.
If your doctor is not confident in diagnosing or treating you, or they think you require more tests, they may refer you to a gynaecologist or other specialist at your local hospital.
How is vaginal dryness treated?
If the menopause is responsible for your lack of lubrication, you may benefit from hormone replacement therapy (HRT).
Oestrogen can be given either systemically to increase levels throughout the whole body, or vaginally to increase levels in this area only.
Systemic oestrogen will also help other menopausal symptoms such as hot flushes. If you have a uterus/womb, this should be combined with another hormone called progesterone. If you have had a hysterectomy, you can take systemic oestrogen alone. Systemic HRT can be taken orally as a tablet, inserted under the skin as an implant, or applied topically as a patch or skin gel.
Vaginal oestrogens may be more suitable if a lack of lubrication is the main issue for you, or if you are unable to take systemic HRT for medical reasons. They can also be used with systemic HRT. These preparations are inserted into the vagina and come as a pessary, ring or cream. Vaginal HRT contains low doses of oestrogen and does not need to be combined with progesterone.
Research has shown that in women using vaginal oestrogen therapy to treat vaginal discomfort, 58% found sex less painful, 41% found sex more satisfying and 29% found it improved their sex life. What’s more, 57% of men looked forward to having sex because of their partner’s vaginal oestrogen therapy.
Several studies have shown a benefit of testosterone therapy in women who have been through the menopause, but mainly in those using oestrogen. In the UK, the only licensed testosterone treatment for many years was an implant put under the skin using local anaesthetic. Testosterone gel and testosterone patches have also been used, but the patches have been withdrawn and the gel is not licensed for use in women.
Tibolone (Livial®) is often classed as a type of systemic HRT. It is a man-made steroid with similar effects to the female hormones oestrogen and progesterone as well as testosterone. It can improve menopausal symptoms and a lack of sexual desire.
It is important to remember that although HRT offers numerous health benefits, it is also associated with some risks, particularly when used systemically. Ask your doctor to discuss these with you.
Complementary and unregulated preparations
There is some evidence that complementary therapies and unregulated preparations may relieve menopause symptoms. Examples include isoflavones, black cohosh and St. John’s Wort. However, many different preparations are available, their safety is uncertain, and they may interact with other medicines.
Vaginal lubricants and moisturisers
If vaginal dryness is a problem, this may be improved with lubricants and moisturisers. These products can be used alone or in addition to vaginal oestrogen.
Vaginal lubricants are used at the time of sexual intercourse. There are many different kinds available and they can be bought over-the-counter. Some are also available on prescription. They may be water-based (e.g. KY® Jelly), silicone-based (e.g. Replens™ Silky Smooth Personal Lubricant) or oil-based (e.g. peach kernel or sweet almond oils). The oil-based products may damage the latex in condoms, and it’s important to remember this if you want to prevent a pregnancy or sexually transmitted infection (STI). Some lubricants may feel better and last longer than others, so it is worth trying the different types to see which works best for you.
Vaginal moisturisers (e.g. Replens™ MD Longer Lasting Vaginal Moisturiser) help retain moisture in the vagina. These can be applied regularly and at least 2 hours before sex. They are available over-the-counter or on prescription.
Cognitive behavioural therapy
If your menopause symptoms are affecting your mood or causing you anxiety, you may benefit from Cognitive behavioural therapy (CBT). This is a type of ‘talking therapy.’ Your doctor may be able to refer you for CBT on the NHS, or you can pay to see a therapist privately – ask your doctor if they can recommend someone locally, otherwise you can find a register of accredited CBT therapists in the UK on the British Association for Behavioural & Cognitive Psychotherapies (BABCP) website www.babcp.com and a directory of chartered psychologists, some of whom specialise in CBT, on The British Psychological Society (BPS) website www.bps.org.uk
If you are experiencing sexual problems, as a result of the menopause or otherwise, you may benefit from sex therapy (see the following section on this). Some sex therapists also offer CBT.
Sex therapy is talking therapy where an individual or couple work with an experienced therapist to assess and treat their sexual and/or relationship problems. Together they will identify factors that trigger the problems and design a specific treatment programme to resolve or reduce their impact.
Sex therapy is considered highly effective in addressing the main causes and contributing factors of sexual difficulties. And it helps people to develop healthier attitudes towards sex, improve sexual intimacy, become more confident sexually, and improve communication within the relationship.
Sex therapy can also be used in combination with other forms of treatment. Your GP or another health professional on the NHS may be able to refer you for sex therapy (depending on area), or you can contact a therapist directly and pay privately. It is important to make sure that they are qualified and are registered with an appropriate professional body. You can find more information on sex therapy in our factsheets ‘Sex therapy’ and ‘How to find, choose and benefit from counselling support’
How can you help yourself?
You may be able to improve some of your menopause symptoms yourself by eating a healthy, balanced diet, maintaining a healthy weight and exercising regularly (for more information see our factsheets, ‘The Mediterranean diet’, ‘Body Mass Index (BMI)’ and ‘Physical activity’).
Finally, having sex is good for you! Sexual activity has been shown to reduce vaginal changes associated with the menopause and women who have sex report fewer vaginal symptoms than those who do not (see our factsheet on ‘Lack of sexual desire/arousal’ for self-help tips on increasing a lack of sexual desire and/or arousal).
What is the Take Home Message?
Menopause-related vaginal dryness should not mean an end to all sexual activity – effective treatments are available
Where can you get more information?
The Sexual Advice Association is here to help. We cannot give individual medical advice, but we can answer your questions on any sexual problems and put you in touch withlocal specialist practitioners. We also have a number of factsheets and booklets on sexual problems and related issues for men and women that can be downloaded from our website or requested. Please feel free to email us or phone our Helpline (our contact details are at the bottom of this page).
You can also visit the NHS Choices website at www.nhs.uk for information and advice on many different health and lifestyle topics.
Download or request our factsheet ‘Explaining sexual problems to your GP’
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Thinking About Sex Day: February 14th
Launched by the Sexual Advice Association, Thinking About Sex Day (TASD) is designed to encourage everyone to think about the physical and psychological issues surrounding sexual activity.