| Sexuality and
Menopause: 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.
Written
by "Alex" Caroline Robboy, CAS,
ACSW, LCSW
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