This is a topic many women feel uncomfortable discussing with me, but believe me- I talk sex with everyone. I may ask you, ‘Is pain vaginal or pelvic?’, ‘How long has your libido been low for?’, ‘How long have you had vaginal dryness?’ There are also women who think low libido is normal, because their friends experienced the same thing when they went through menopause. There are also women who think that getting older means a less satisfying sex life, but remember, common does not always equal normal. We have patients 70+ who are still sexually active! Yes, that is plural!
What actually happens to the body during menopause?
Women are born with a finite number of eggs which are stored in the ovaries. The ovaries are also responsible for producing estrogen and progesterone. Menopause is a normal part of aging, but women may experience this sooner if they have had surgeries like a complete or partial hysterectomy, or removal of ovaries due to PCOS or endometriosis (6).
Menopause begins with a phase called perimenopause (5). This phase can last anywhere from 2-10 years! At this stage, estrogen levels begin to drop and this may be when women start to experience the symptoms that are associated with menopause: hot flashes, night sweats, low libido, low energy, etc. Menopause itself is the point where its been 1+ year since a woman has had a period. The ovaries have quit making most of their estrogen at this point. Now the adrenal glands are in control of producing and releasing sex hormones in women.
Let’s talk more about the decreased libido-
It’s estimated that up to 26% of postmenopausal women suffer from low libido. Estradiol (E2), or the estrogen dominant during menstruating years, and testosterone have been implicated as the steroids necessary for giving women sexual desires. Testosterone is produced in the ovaries, adrenal glands, and peripheral tissues. Testosterone can be converted into estradiol directly, and over conversion of this may lead to low testosterone and high estrogen. Or, the woman may suffer from both low testosterone and low estrogen.
Research has identified that women may benefit from testosterone for increasing their libido (7). Other studies have shown benefits of giving both estrogen and testosterone for the improvement of libido (6). The more I talk to women, sometimes I realize the lack of sex isn’t due to lack of libido, but fear of pain or discomfort associated with intercourse.
It is estimated that up to 20% of women (globally) may experience painful intercourse (1). These are the top 5 things that I see cause painful intercourse, or dyspareunia:
- Decreased lubrication
- Vaginal lubrication is triggered by increased blood flow toward the genitals when aroused. The fluid is produced by two glands that sit on the edge of the vagina called Bartholin’s Glands. The fluid from these gland is different from vaginal discharge and is much more slippery. Estrogen is required for production of lubrication (this is why you may notice lubrication vary throughout the month when menstruating).
- Hormonal changes
- As the transition into menopause occurs, hormone production decreases significantly. Decreased estrogen levels can cause the vaginal lining and lining of the urinary tract to thin (2).
- Recurring yeast infections may increase pain with intercourse. Research has found that pain may persist for at least 3 weeks after resolution of infections (3). Yeast infections can be transmitted sexually and can also occur after a round of antibiotics.
- Fibroids, also known as leiomyomata, affect most women at some point in their lives. It is estimated that by age 50, 70% of caucasian women and 80% of african american women have fibroids (4). Many of these women may be unaware that they have them. Interestingly, fibroids are usually formed due to too much estrogen or too little progesterone (so in this case, giving estrogen is NOT recommended). These fibroids can cause sex to be painful, many of these women noting more pelvic pain than vaginal pain.
- Vaginal tissue can begin to atrophy, or decrease in size as the amount of estrogen produced begins to decrease. Our ovaries produce most of our estrogen and progesterone during menstruating years, but as we transition through menopause, the adrenal glands become the main producer of our sex hormones. As a result of the decrease in production of sex hormones, in particular estradiol (E2), we may start to see atrophy of the vaginal tissue (1). This may cause: itching, vaginal dryness, and dyspareunia.
So what to do?
The first thing you should do is have your hormones tested. Taking hormones without seeing what your levels look like is potentially dangerous and may worsen your symptoms.
With that being said, I DO NOT recommend synthetic hormones. Research has shown that oral estrogen therapy can lead to increased levels of thyroxine-binding globulin (TBG) (8). What happens is TBG tries to grab as much free thyroxine (T4) as it can to bind to its receptor sites. When T4 attaches to TBG it is no longer available for use in the blood. The brain interprets this as low T4, and as a result begins to overproduce TSH.
Some natural alternatives for improving sexual complaints:
Red Clover (trifolium pratense): This herb is well known for its isoflavones, which is a type of phytoestrogen (plant estrogen). It can stimulate estrogen production in the body, and depending on hormonal levels, it may also have progesterogenic properties as well. One study by Obstetrics and Gynecology International found that Red Clover use for 90 days showed improvement in hair and skin, libido, moods, sleep, and energy (9).
Ashwagandha (withania somnifera): This herb is an adaptogen, a herb that helps the body respond more efficiently to stress by decreasing cortisol levels. It has also been longed use for its ability to treat sexual dysfunction. After 8 weeks of taking 300mg twice daily of Ashwagandha, women reported improved sexual desire, arousal, lubrication, orgasm intensity, and sexual satisfaction (10).
Tribulus (tribulus terrestris): This herb contains saponins which act on androgen metabolism, meaning it can help to increase DHEA and testosterone levels. One study measured women who took 7.5mg/day of tribulus for 4 weeks, and noted at the end of the treatment period improvements in desire, arousal, lubrication, satisfaction, and pain (11).
Magnolia and Chastetree (Magnolia officinalis, Vitex Agnus-castus): Magnolia has neurotrophic and and has antihistamine properties. Chaste Tree has long been used for its benefits to the female reproductive system, but research has shown that a combination of these two, may be most effective (12). In this study over the course of one year, women received 60mg lactobacillus sporogenes, 50mg Magnolia officinalis, 40mg vitex agnus-castus, and 35ug of Vitamin D daily. There was a significant reduction in hot flashes, improvement in sleep, and improved sexual function (12).
Ginko Biloba: This herb is well known for its ability to improve blood flow and is neuroprotective. Recent evidence has shown that it can also improve libido. Participants received 120-240mg Ginko Bilobo daily for 30 days. Women reported increased sexual desire as well as improved vaginal dryness and overall sexual function (13).
Final thoughts on improving your sex life.
- Many factors can affect sex drive in women, such as hormonal dysfunction, thyroid function, confidence in body image, satisfaction with your partner, depression/anxiety, and medications.
- Estrogen levels decrease with menopause, and if they decrease too quickly may be the explanation for menopausal symptoms. Low testosterone can also affect libido. Having your hormones properly evaluated is crucial.
- Adding herbs into your daily routine and decreasing inflammatory foods like alcohol, gluten, and dairy may help.
- There is lots of information on the internet, but the best way to improve your symptoms is to work with a doctor to help establish the best plan for YOUR body.
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