Let’s talk about sex, baby
In perimenopause and menopause, it may be different — but it doesn’t need to be over.
Recently, I was at dinner with a group of women in their 40s through 60s. The conversation quickly turned to perimenopause and menopause — and how hard it can be to decipher whether something is even a symptom of changing hormones or not. Why do your ears suddenly itch! Why does the sound of your husband breathing suddenly send you into a rage!
“And that’s all before you even start to deal with the sex stuff!” someone said. Everyone moaned — but not in a “When Harry Met Sally” way.
The “sex stuff” is something that many of our newsletter readers have been wondering about too.
One reader wrote asking for more information on changes in sexual desire and what coping tools or healthy changes she could make to increase desire.
Another wrote about her newly “non-existent libido” and the fact that sex has become physically painful and anxiety-inducing for her. “Vast quantities of lube” are not cutting it, she said.
I know this is something so many of us are grappling with — so, in the words of Salt-N-Pepa, let’s talk about sex, baby.
Cue the expert
Courtney Shihabuddin is an assistant clinical professor at Ohio State University College of Nursing, where she serves as the specialty track director for the adult-gerontology primary care nurse practitioner program. She’s also a practitioner herself and a member of the Menopause Society, which provides evidence-based resources to health care professionals on menopause and midlife.
She has made a career out of providing care for women in middle age and training others to do the same — and making sexual health part of the equation. And all of this is why I wanted to talk to her about our sexual health as we age.
The first thing Shihabuddin told me is that women deserve to have healthy sex lives throughout perimenopause, menopause and beyond — and how strongly she believes that they deserve medical care that helps them do so.
A biology lesson
As you are well acquainted with by now, from puberty to menopause, your body releases eggs periodically. It’s a big job for your body to do every month-ish — and is a process largely fueled by your hormones.
During perimenopause, this can get a little hairy because your egg supply is dwindling down to zero. Some months you ovulate, some you don’t. It’s all part of the wind-down toward menopause, and it can mean wildly fluctuating levels of hormones, especially the estrogen that helps push that egg to release (but now, only sometimes). “We’re in this up and down zone of chaos,” Shihabuddin said.
Estrogen isn’t the only hormone fluctuating here. Progesterone also plays a major role in your hormonal life, and its levels are directly tied to symptoms like irritability, moodiness, tearfulness — all of these pre-menstrual symptoms can come a lot more frequently, albeit erratically.
And then there’s testosterone. As testosterone decreases as a result of the lack of ovulation, it can also cause symptoms like low sex drive, fatigue, loss of muscle tone, vaginal dryness, depression and anxiety, thinning hair, dry skin and sleep disruption. It’s the hormone most associated with libido — but because of the general lack of research into menopause generally, it is still unclear if low testosterone is something that needs to be addressed to help women have fulfilling sex lives in the second half of life.
All of the many hormone fluctuations mean lots of different kinds of side effects — like genital urinary symptoms that can cause not only painful sex but increased urinary tract infections and micro tears to the vulvar tissues even from just wiping with toilet paper.
Long story short: Lots of hormones changing, lots of new symptoms that can take a real toll on your sex life.
But you’re not doomed!
The wide range of symptoms that can affect different facets of sexual health can make it that much harder to get the care you need. Someone who is experiencing low libido may not need the same things as someone who is experiencing frequent yeast infections — who may not need the same things as someone experiencing vaginal dryness.
Untangling all of this takes not only a patient who isn’t afraid to ask, but a practitioner skilled and comfortable enough to listen — and to want to help.
“This whole area of medicine in general is just ignored by providers because it’s just not taught,” Shihabuddin said. “Midlife women’s health is just not addressed. And sexual health is really something that is always thought of as someone else’s problem in terms of medical education.”
Ensuring that people going through perimenopause and beyond can have good sex if they want to also means validating patients’ experiences and listening with sensitivity and understanding to someone who says they are experiencing pain.
“If something hurts and it repeatedly hurts, our brain starts telling us, ‘Don’t be stupid — stop doing the thing that is hurting you.’ So a lot of the time, when a patient comes to see me and they’re complaining about lack of interest in intercourse, we have to get to the bottom of what’s happening,” Shihabuddin said. “Do you just not want to have it, or do you want to have it but it hurts? And if the latter, does it hurt inside the vagina or externally, around the labia and the clitoris? Are you having pain with intercourse only or pain all the time?”
Research shows that good sex is tied to a number of factors, not just hormones. And a good practitioner is going to work to address symptoms holistically.
For some people, the solution may be topical estrogen (which just lost its black box labeling from the FDA) to address vaginal pain, atrophy or recurrent UTIs. For others, it might be systemic hormone therapy to address sleep disturbances. It might mean addressing underlying health issues like anemia that can translate into low libido. Or it could mean looking into antidepressants to treat a mood disorder that’s keeping you from being, well, in the mood. It might not even be that medication is what you need, but a good therapist or some techniques to help with mind-body connection.
But, as we have discussed many times in this newsletter already, at the root of this problem is the way sexism has influenced medical research and practice.
OK, but back to testosterone
The current guidelines from the Endocrine Society, published in 2014 and endorsed by the Menopause Society, recommend against making a diagnosis of “androgen deficiency syndrome” — or, a lack of testosterone — in healthy women “because there is a lack of a well-defined syndrome” and little data correlating testosterone levels with certain symptoms. (The one exception is cisgender postmenopausal women with diagnoses of hypoactive sexual desire disorder, who can be safely treated with testosterone for a short time.)
A 2024 article published in the Journal of the Endocrine Society noted that the potential cardiovascular risks of testosterone therapy in postmenopausal women are still understudied and in need of further research.
The shortage of research on menopause generally — and the consumer demand for solutions — has also led to a largely unregulated Wild West of testosterone therapies, with independent clinics offering things like testosterone injections and pellets that you might know from “Real Housewives” episodes. These treatments were originally formulated for men — and mostly introduce much more testosterone to the body than the amount the cisgender female body would ever make, even pre-perimenopause.
Again: There is a major double standard in medical research.
“Try telling a man with increased urination that he just needs to live with it. Or try telling a guy at 40 who can’t get an erection that he’s just never going to have sex again,” Shihabuddin said. “Like no — those things are addressed immediately. They are well-funded. They have a lot of drugs behind them.”
The prime of our lives
But there are clinicians who really do want to help — and yes, like the Salt-N-Pepa song goes, really want to talk about sex and figure out what might help, both in terms of medication and lifestyle changes. (A good place to start is checking the Menopause Society’s practitioners database.)
Shihabuddin does think things are changing exactly because of the drive this current generation of perimenopausal and menopausal women have. They’re fluent in all things Internet and are not afraid to ask questions — and push for answers, including when it comes to wanting to have the kind of sex lives they know they deserve.
“We are in the prime of our lives. We should also be having the best sex of our lives,” Shihabuddin said. “And if I’m not, I want to know why and I want to know how to fix it.”
Some news about … masturbation
A new study published last week in the journal of the Menopause Society looked at the potential role of masturbation in the relief of symptoms associated with menopause.
Researchers had a demographically representative sample of 1,178 women in the United States between the ages of 40 and 65 complete an online survey about the strategies used to manage their perimenopause and menopause symptoms and the efficacy of these strategies.
Nearly 1 in 5 of the women surveyed reported that masturbation provided symptom relief — and was rated among the best symptom relief measures when it came to mood changes and sleep disturbances. And nearly half of the women surveyed said they would be open to trying masturbation as a strategy for symptom relief if their doctor recommended it.
The researchers noted that because health conditions and physical limitations can impact older women’s ability to comfortably masturbate, more research and development of sexual wellness toys and products specifically for this demographic could help make masturbation an option for even more women and give providers more options for patients experiencing symptoms.
I almost forgot
If you’re reading this, this means you’re also old enough to have watched “Daria” when it was first airing on MTV (and maybe to have also had a crush on a cartoon character; yes, we are talking about Trent Lane).
I was just talking to some friends about how watching “Daria” was so deeply formative in my middle and high school years — how seen it made me feel and how much it also shaped my sense of humor.
But something else I mentioned is how now that I’m in my 40s, I also have a new appreciation for a real unsung hero of the show: Daria’s mom, Helen Morgendorffer. She was often portrayed as a harried workaholic, devoted to her job as a corporate attorney above everything else, but I’m here today to say JUSTICE FOR HELEN.
This woman was the breadwinner of her family, unapologetic about her desire to work, the role that her work played in supporting her family, and the seeming pleasure (despite the stress) her work gave her.
She managed to keep clueless husband Jake in-line, parent two daughters with opposite but outsized egos in Daria and Quinn, and gave a real ahead-of-its-time look at the complex emotions that women do in fact feel about work and home life.
She tries to give Daria advice, she tries to act like the Fashion Club is a serious pursuit, she shows up at all the things — and often feels bad about wanting to be at work even as she is committed to making a point to show up for her family, no matter what.
It’s time for a cultural re-examination of Helen Morgendorffer! If nothing else, no one screamed on the phone quite like she did.