Midlife Sex Crisis: What Are My Perimenopause Options?

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You hit your 40s or 50s and all of the sudden things start spiraling: Your period is out of whack, your undergarments are damp with urine after a one mile walk with your dog, and you can no longer wear your favorite jeans because they’re irritating to your lady parts. As if that wasn’t enough to deal with, you also wake up in the middle of the night in a puddle of sweat, you have to forgo the post-dinner tiramisu because you know it’s already going to take three times as long to exercise away the two glasses of wine you’ve consumed, and you’re in bed an hour before your partner because sex is uncomfortable. Of course, these are all quite animated examples, and women that are perimenopausal may or may not experience  irregular menstrual cycles, urinary incontinence, vaginal dryness, hot flashes, interrupted sleep, weight gain, and painful intercourse. But because these symptoms are possible,  it’s important to understand the changes our bodies go through midlife so we can find ways to mitigate some of these unpleasantries.

 

True menopause is defined as the absence of your menstrual cycle for 12 consecutive months, however, symptoms can creep in sooner during the perimenopausal stage. So what exactly happens to our bodies during this time that funnels them into this craze? In the simplest of terms, when we reach perimenopausal age there is a natural decline of the reproductive hormones released by the ovaries. These include estrogen, progesterone, and testosterone. Rachel wrote a fantastic post highlighting the functions of these hormones. As Rachel discussed, the reproductive hormones play an integral role in maintaining healthy vulvovaginal tissue. Because these tissues are hormone-dependent, the decrease in available reproductive hormones during menopause can lead to pelvic floor muscle strength deficits, decreased elasticity of the vaginal walls, decreased lubrication, and secondary irritation of the vestibule and external genitalia atrophy. For these reasons, perimenopausal women can sometimes experience pain with intercourse, or “dyspareunia.” It is estimated that up to 40% of women hovering around menopause experience painful sex, but only half of these women seek medical assistance.1 This statistic is shocking, as dyspareunia can have negative implications on quality of life. In a cross-sectional study examining the differences in sexual function and quality of life between perimenopausal women with and without dyspareunia, those with dyspareunia reported impaired sexual function (e.g., diminishing arousal, inadequate lubrication, less frequent orgasm) and decreased quality of life.5

 

Fortunately, “menopause-induced” dyspareunia is not a life sentence. Let’s go ahead and debunk the myth that once you hit menopause, painful sex has to become the the new normal. Yes, menopause is part of the aging process, but by no means should it interfere with your ability to have a healthy, satisfying, and pain-free sex life. Thankfully, there are many options available to help counteract or manage some of the vulvovaginal changes with menopause and associated painful intercourse:

 

  • Hormone Replacement Therapy –  To some women, the words “hormone replacement therapy” sound scary.  After findings from studies such as The Million Women Study and those performed by the Women’s Health Initiative were released in the early 2000s, many perimenopausal women have been resistant to going this route because they suggested that women who participated in hormone replacement therapy had an increased risk of heart-related conditions and cancer.  However, some in the medical community have met these conclusions with resistance, stating that either the doses used in these studies were too high or that the sample groups consisted of women way past menopausal years. Read more about how to  differentiate quality studies from the not-so-great ones. Subsequent studies have since found no significant differences in these risks and have stated that hormone replacement therapy is effective in managing menopausal symptoms.  However, if you have a history of reproductive hormone cancers such as breast or ovarian, hesitancy may be warranted. But have no fear, there are many other options for you which you can find below.
  • Localized Hormones (i.e. Estrace, Vagifem, Estring) – As opposed to the systemic delivery of hormones via hormone replacement therapy, localized hormones in the form of a topical cream, insert, or ring may be a good alternative as they only target adjacent vulvovaginal tissues. These can be prescribed “off the shelf” or compounded with a base that is agreeable with you and your body. It can take weeks to months to start to see positive tissue changes with localized hormones so being patient with the process is key. A critical review of the literature suggests localized topical hormones can improve menopause-initiated vaginal tissue changes and associated symptoms.1
  • Lubricants (Water-, Petroleum-, Natural Oil-, Silicone-based) – Lubricants are a non-hormonal option that can help bring moisture back to the vulvovaginal tissues. Because they are non-hormonal, they do not exactly mimic the effects of the above hormonal options, but can be used to help manage vaginal dryness and pain during intercourse. There are many types of lubricants available, and something as simple as coconut oil or as fancy as Vital V Wild Yam Salve can be used as a lubricant. Visit Melinda’s post for more specifics about lubricants.
  • Phytoestrogens – If you prefer to go an even more natural route, phytoestrogens may be a good starting point for you. These are naturally occurring plant compounds that have estrogen-like properties and can be found in products such as soy, lentils, flaxseed and berries. The jury is still out on whether or not they directly affect the vulvovaginal tissue, but there have been some anecdotal success. Specific dietary guidelines are still being explored.2,4

 

If you’re approaching menopause and have noticed any vulvovaginal tissue changes or experience pain with intercourse, you may want to consult with your physician about one of the above options. In addition to addressing the tissue changes, you may also consider consulting with a pelvic floor physical therapist. In some instances, especially in the case of longstanding dyspareunia, the muscles of the pelvic floor may guard as an innate protective response to pain. When the pelvic floor muscles rest in this contracted state, they decrease the blood flow to the area and can cause more pain creating a negative feedback loop. For cases such as this, a physical therapist can perform manual techniques and teach you strategies to help relax the pelvic floor muscles and restore normal mobility. Here’s what you can expect with pelvic floor physical therapy. This in combination with treatment specific to the vulvovaginal tissues can help reset you to a pain-free and pleasurable sex life.

 

As an aside, it is also worth mentioning that any decline or alteration in the reproductive hormones can cause similar menopausal-like vulvovaginal tissue changes and potential dyspareunia. These include history of hysterectomy, radiation to the pelvis or use of oral birth control pills. Check out the links to read up on some of these specifically!

 

 

References:

 

  1. Alina Kao, Yitzchak BM, Kapuscinski A, Khalife S.  Dyspareunia in postmenopausal women: A critical review.  Pain Research and Management. 2008;13(3):243-254.
  2. Glazier MG, Bowman MA. A review of the evidence for the use of phytoestrogens as a replacement for traditional estrogen replacement therapy. Archives of Internal Medicine Journal. 2001;161(9):1161-72.
  3. Kingsberg S, Kellogg S, Krychman M.  Treating dyspareunia caused by vaginal atrophy: a review of treatment options using vaginal estrogen therapy.  International Journal of Women’s Health. 2010; 1:105-11.
  4. Patisaul, H. B., & Jefferson, W. (2010). The pros and cons of phytoestrogens. Frontiers in Neuroendocrinology, 31(4), 400–419.
  5. Schvartzman R, Bertotto A, Schvartzman L, Wender MC. Pelvic floor muscle activity, quality of life, and sexual function in peri- and recently postmenopausal women with and without dyspareunia: a cross-sectional study. Journal of Sex and Marital Therapy. 2014;40(5):367-78.

FAQ

What are pelvic floor muscles?

The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.

What is pelvic floor physical therapy?

Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.

What happens at pelvic floor therapy?

During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.

What is pudendal neuralgia and how is it treated?

Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.

Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.

What is interstitial cystitis and how is it treated?

Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.

Who is the Pelvic Health and Rehabilitation Team?

The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.

How many years of experience do we have?

Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.

Why PHRC versus anyone else?

PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.

Do we treat men for pelvic floor therapy?

The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.

Do I need pelvic floor therapy forever?

The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.

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