Sex and Menopause

Podcast Transcript

Erica Newlin, MD:

Welcome to Ob/Gyn Time, a Cleveland Clinic podcast covering all things obstetrics and gynecology. These podcast episodes are intended to help you better understand your health, leaving you feel empowered to live your best. We hope you enjoy today's episode.

Hi everyone, I'm your host, Dr. Erica Newlin. Welcome to Ob/Gyn Time. During this season, we are focusing on topics related to menopause. On this episode, I'd like to welcome Dr. Salena Zanotti who will be talking to us about sex and menopause.

Dr. Zanotti, thanks so much for joining me on the podcast.

Salena Zanotti, MD:

Oh, thank you for having me here. I'm excited to talk.

Erica Newlin, MD:

Can you tell us a little about your role in the Cleveland Clinic and a little about your background?

Salena Zanotti, MD:

Sure. I am an OB-GYN at the Cleveland Clinic. I've been here over 18 years. I've been practicing for over 20 years. I have a general practice, but I also have a special interest in sexual health.

Erica Newlin, MD:

Great. Let's start by talking about what changes people may expect to their body as they're going through menopause and beyond. Could you start by defining the different terms we use to describe the external female anatomy?

Salena Zanotti, M:

Sure. You know, menopause is an interesting time and I think a lot of women are worried about perimenopause too, which is the time before menopause, and perimenopause is when our hormones start changing and our ovaries aren't functioning as much. You're menopausal, really, once those ovaries have stopped working and we're not making as many hormones. And everyone thinks about hormones like estrogen and progesterone, but women also make hormones that are, you know, classified or called sort of male hormones or androgens, testosterone and a few other ones, and those start declining as well. They don't stop completely at menopause, we still make some, but slowly over time they go down. You know, and that's what makes changes to our body, different parts of our body, but more importantly, the genitalia. A lot of times you'll see changes on the outside where the skin might get a little bit saggier. The clitoris changes a little bit, the skin gets thin around there, and also there are a lot of changes inside the vagina. I know a lot of women will complain of feeling dry or irritated, and that's without intercourse too. Um, but then obviously when the vagina gets thinner, that women will tend to have some pain with sex which is probably the most common thing that's brought up. The vagina also loses some of its elasticity. You know, it starts getting a little bit more tight or rigid and that can cause pain, and so those are some of the changes that happen.

Erica Newlin, MD:

We throw around the term atrophy a lot. Can you explain what that means?

Salena Zanotti, MD:

Yeah, atrophy means basically the thinning that happens, the change in the skin in the vagina or the mucosa. We used to call it vaginal atrophy, but it actually has a name now, a real name, called Genitourinary Syndrome of Menopause, GSM for short, much easier to say, but those are changes that happen in the area and we changed it so it's not just about the thinning, because there are changes that affect your urinary symptom. You know, because of these changes, some women get bladder infections a lot and that's just because of the lack of estrogen in the area, and so you get some urinary complaints, you get the dryness complaints that cause some of that pain, but the atrophy is really talking about the changes from lack of estrogen to that entire area.

Erica Newlin, MD:

Mm-hmm. And I have some patients who feel like their labia, or their outside lips are smaller, their inside lips are smaller.

Salena Zanotti, MD:

Exactly, everything starts thinning out, regressing a little bit.

Erica Newlin, MD:

Mm-hmm, and then you mentioned pain with sex. Can you talk about what interventions are available or what things are available kind of over the counter in someone who's having pain with sex?

Salena Zanotti, MD:

Yeah, you know, it depends sort of what's the cause of pain with sex, you know, and it's sort of this catch-22, and now I talk to my patients, they start having sex less often for several reasons, one is just life, changes that happen, stress, lack of desire so they don't necessarily have intercourse as often, and then they're having pain and so they have intercourse less frequently because of the pain. And what happens also over time, and I'll talk about the dryness issue, but over time when you're having less sex, the vagina gets sort of less elastic and tighter and then it hurts to have sex. So, you sort of have to do it more often to relieve some of that pain.

But for the dryness, there's a few options that are over the counter and I think where women get confused, like if you go to CVS, there's just a million things on, you know, on the rack and you don't know what's what. There's a difference between moisturizers and lubricants and I think that's really important for women to understand. A moisturizer is something that you place in the vagina, having nothing to do with intercourse, usually, two, three, four times a week, and you want to apply it internally as well as externally. And there are several different ones on the market. So, there are some that they're mostly water-based, and these do not have any hormones in them if people are worried about using hormones. There's water-based ones, there's some newer ones that have hyaluronic acid in them and those have been found to really do well with increasing the moisture in the vagina. So that's one thing you do sort of as a maintenance.

And then there's lubricants you use when you're actually gonna be sexually active and there're a lot of different lubricants out there. There's some water-based ones, there's silicone-based ones. You know, we're talking about menopausal women, so we're not worried about contraception and condoms although they should be concerned about STD prevention if it's a new partner no matter your age but depends on sort of how sensitive your vagina is what kind of lubricant's better for you. And everyone's vaginas different. Some are irritating, some are not. A lot of women do well with a silicone ones. They seem to just be more comfortable and enhance the whole experience. There's some common ones you can get, like I said over the counter. Amazon's great for these things too so those are things you're gonna use when you're having intercourse. And I think it's feeling comfortable with your body and your partner is very important to be able to use these and so I'll tell patients, you know, "Either you can apply it yourself, the lubricant, put it at the opening of the vagina and then inside a little bit too, or your partner can do it as part of foreplay and that can enhance the whole experience too."

And so, a lot of times you need to use that moisturizer and the lubricant. You know, some women may be okay with just the lubricants, so I think it's figuring out what's right for them.

Erica Newlin, MD:

Mm-hmm. And I like that you pointed out there could be a lot of different reasons for pain with sex even with menopause, because there's the whole basket of pelvic floor muscles and so we don't want to miss any pelvic floor dysfunction too.

Salena Zanotti, MD:

Yeah, you know, there's a lot that can happen in that area. You know, a lot of it's not just because of menopause, there are some skin conditions that occur in women, something called lichen sclerosus or lichen planus that are real conditions that change sort of the look and the architecture of the vulva and the vagina, which can cause pain for women, especially upon entry. You know, the introitus, which is the opening to the vagina, can get very thin and some of these other skin changes can make that skin break down, which will cause a lot of pain with initial entry. And like you brought up; pelvic floor is so important, and I think it’s something we're just really appreciating more recently for all ages.

And there are many muscles that line the pelvic floor. There's a lot of nerves there. And just like if you have tight muscles somewhere else on your body, you can have pain. If you have tight muscles in the pelvis, you can have pain, you can have nerve pain because of that as well. And so, it's really important to see a provider if you're having more deep pain and to have that evaluated.

Erica Newlin, MD:

And then you mentioned seeing a provider if you're having more of the deep pain. When might someone want to see their doctor for pain with sex as opposed to going straight to over the counter?

Salena Zanotti, MD:

Yeah, I think any time, you know, just so you can talk about the options. You know, a lot of women, and this is changing, which I'm really happy to see in my practice, but before, women were hesitant to talk about sexual concerns like it was taboo, but now a lot of women will bring it up, you know, and I hope more providers are asking because I think it's such an important part of our health, for physical health and mental health, but a lot of women do bring it up, so I think if you're having pain that's persisting with intercourse, you know, it's important to talk to your provider because they might talk to you about those over-the-counter options a little bit more as well as talk to you about some pharmaceutical options you have. You know, and a lot of other options besides just managing the dryness if it's getting tighter, you know, there's dilator therapy that we can talk about and so your provider can talk to you about that.

And fortunately, pelvic floor physical therapy has become a huge part of taking care of these patients.

Erica Newlin, MD:

Mm-hmm, I love our pelvic floor physical therapists.

Salena Zanotti, MD:

They're fantastic.

Erica Newlin, MD:

Yeah.

Salena Zanotti, MD:

We're very lucky here in Cleveland. We have some great ones, and a lot of cities do but they really help with so many different aspects of pelvic pain, whether it be sexually related or not sexually related, urinary issues, and help women of all ages so, I think that's important and that's something, again, seeing your provider, whether it be your women's health provider or primary care provider who can manage that.

Erica Newlin, MD:

Yeah, it's often something that I bring up at the annual visits and around I'd say maybe half of the time it leads to a discussion on things, so definitely I tell patients not to be embarrassed to bring it up, it's something, like, would be weird if you brought it up at the dentist, not so much at the gynecologist.

Salena Zanotti, MD:

Exactly. And I'm glad you bring it up because people do need to ask. You know, and it's just a simple, open-ended question, you know, "Do you have any sexual concerns?" And a lot of times, you know, it'll just start, and there's a lot going on there and so, you know, and you might have to bring a patient back for another visit because there is so much to talk about, but it's important to and I think patients need to be comfortable with that.

Erica Newlin, MD:

Yeah. Great. And then we mentioned just over-the-counter interventions. What prescription interventions are available?

Salena Zanotti, MD:

So, when you're finding that your pain is from the changes that happen from lack of hormones from the lack of estrogen or atrophy like you called it, there are a few options. There's vaginal estrogen, and, you know, a lot of women are very scared when they hear about hormones and unfortunately, that happened because just marketing and different studies that happened years ago, but we know that hormones can be used safely in majority of women for different reasons. But vaginal estrogen, I think, is so important for women to consider. It just works locally in the vagina. It's not systemically absorbed so if you're worried about other things, potential risks, you don't need to be with vaginal estrogen.

And I talk to a lot of my patients as they're going through perimenopause is, "Let's talk about using vaginal estrogen before you become symptomatic, you know, once you're menopausal," because what happens is a lot of women wait and then they show up maybe when they're 60 and they've been five or 10 years postmenopausal and the changes are so significant it's hard to get back what you used to have, whereas if you start using vaginal estrogen at the onset of menopause, you're gonna prevent these changes that happen. And I tell women, you know, "Using it, you want to use it as long as you think you want to be sexually active and for everyone that's very different." You know, a lot of women and their partners are comfortable not being sexually active, which is fine. I have patients well into their 80s who want to stay sexually active, which is fantastic. So, using estrogen, number one, to prevent changes I think is important, but then also to treat the changes once they've happened, and we have few different ways women can use estrogen. There's a cream that you can apply with an applicator, there's a small tablet that can be placed into the vagina, as well as a vaginal ring and they all have different frequencies of use and how you use them. And, you know, the vast majority of women can use them, there's very rare cases that we can't.

The other pharmaceutical agent that's out there is DHEA, which is another kind of hormone that gets converted to estrogen in the vagina, and that comes in a suppository. And that, again, is very efficacious in the same kind of situation, but these things take time and that's the other thing. I do tell women, you know, "We'll start something, you're not gonna see results for a couple months and so it's important to stick with it, still have intercourse, use those over-the-counter things we talked about to help with pain, but you will see improvement." And we do know, like, the estrogen and the DHEA also help, you know, increase some blood flow to the area so for some women, it can help the experience as well. But without a doubt, if you get rid of the pain or decrease the pain, women are gonna have more desire and obviously enjoy the whole experience.

Erica Newlin, MD:

Great. And then now to switch gears a little bit, let's talk about libido changes, kind of meaning the changes in desire to have sex. What might people expect as they approach kind of perimenopause, menopause?

Salena Zanotti, MD:

Yeah. You know, female desire's complex. We're very different than men, as we know. Multiple things affect our desire and that happens, you know, to women in their 30s and 40s when you have kids and you have stress and different things that contribute, but then as we go through menopause, there's multiple factors that are hormonal, you know, like we talked about, you lose your estrogen, progesterone, over time your testosterone decreases, as well as some other hormones, and so that can affect our desire. Then you're having intercourse less frequently so less desire, and then if you add pain into it, nobody wants to have sex if it's gonna hurt. Nobody wants to do anything that hurts. That's, you know, it's a self-defense mechanism.

Salena Zanotti, MD:

And so, if you're having pain, you're not going to want to have intercourse or any kind of relationship. And so, all those things contribute to desire and so it's important to address what's going on.

You know, there are also medical conditions, you know, as we get older. Some women might have thyroid disease or, you know, depression and anxiety are real issues, and a lot of those medications might affect desire. So, it's looking at what is causing the desire and it's usually not just one thing that's causing the desire issue. And so, it's addressing those things with your provider, which is really important.

Erica Newlin, MD:

Yeah.

Salena Zanotti, MD:

You know, another thing that I think once someone described it to me this way and I think it's perfect, you know, when you're younger, we have spontaneous desire. You know, we want, it just out of nowhere you think about it, being sexually active in whatever way you want to be. As we get older, it becomes more reactive and so we need to explain that to our partner as well. Desire is there, it just, we need something to sort of create it and sort of ignite the fire a little bit more. And so again, it's talking about that with your partner, and I think that's so important too. And to realize there's nothing wrong with you, these are just things that happen.

Erica Newlin, MD:

Mm-hmm. Sometimes I'll recommend a patient, particular- in the subject of provoked desire, like, figure out what provokes your desire and sprinkle that through the week whatever your thing happens to be.

Salena Zanotti, MD:

Exactly and everyone's different and you just need to make it happen. And if this is important to you, you need to, just like you would with any other part of your health. And I think a lot of women are embarrassed to say this is important for them.

And, you know, your desire can be provoked, you know, with vibrators and do it yourself too and a lot of women do and that's okay and I think women are embarrassed to admit that they'll do that, especially older women. But that's important to do because again, the more you're stimulated the more you're going to want it. And so, I think that's really important for women to do, even if they don't have a partner right now. They can self-stimulate so that that enhances blood flow and keeps things moving and things like that too, so I think that's important.

Erica Newlin, MD:

For sure. If those initial interventions aren't helping, what prescription medications are available?

Salena Zanotti, MD:

Yeah, you know, it's terrible. We don't have really anything that's FDA approved for postmenopausal women. You know, for men, we all know, we got lots of options, but we've been very limited, they've looked at different things and there are some things approved for premenopausal women and data does show that it can help in postmenopausal women, hopefully we'll get more studies so that we can get that approval on it.

Things on the market a pill you take daily basically to help increase desire and again, before you start these things, we need to make sure there's nothing else going on, right? Another, there's an injectable medication that's out there. There's an antidepressant that can help with sexual desire, but again, these are all off-label uses in a postmenopausal woman.

A lot of times, you know, hormone replacement can help, it's not indicated for sexual desire but if it helps with a lot of the other symptoms you're having like hot flashes, mood changes, sleep issues, vaginal changes, that may help your desire, and again, help your experience as well.

There's off-label use of testosterone that we use that can help desire as well, but you've got to be very careful and make sure you're going to a provider that's monitoring your levels because excessive testosterone in a woman can be dangerous.

So, there are more options than before but unfortunately, none of these are FDA approved options.

Erica Newlin, MD:

Yeah, for sure. And then I find that particularly with hormone therapy or other therapies, that body image goes a long way so if people are feeling better, then they're more likely to want to have sex too.

Salena Zanotti, MD:

Great point. And I think that's really important. Also addressing, you know, their overall wellbeing. Are they exercising? How’s their diet? Help them lose weight because you're right. If you don't feel good about how you look, that affects your desire because you don't want someone else seeing you either. Like if you're having those hot flashes or mood changes and those are things we can help with hormone replacement, women definitely feel better.

Erica Newlin, MD:

And you mentioned testosterone. Can you briefly talk about things like testosterone pellets.

Salena Zanotti, MD:

Yeah, so there's different ways to get testosterone. A lot of women probably hear about these pellets that you can have injected, and we don't recommend them because they really can cause high super physiologic levels and women love it because they feel great and they have a lot more desire, but they're in levels that are much higher than any woman should have. You know, we don't need to have the same levels of a man, so it's a little more dangerous but you just need to be monitored really closely if you choose that.

A lot of times will use testosterone cream that you can apply as well, and again, those levels need to be monitored too, and so there's different ways to get it. There's gel and patches that have been looked at as well, but again, it's just close monitoring.

Erica Newlin, MD:

Great. Can you talk about the role of a sex therapist? Like what a sex therapist does?

Salena Zanotti, MD:

Yeah, no, that's a great point. You know, I think therapy is wonderful for everything, you know, we probably all need a therapist for something, but sex therapists work on the many different levels of sexual issues, whether it be a desire issue. You know, a lot of times there can be orgasmic or arousal issues, and a lot of times they're issues that are arising from when we're a lot younger that need to be addressed and so, a sexual therapist number one, can help figuring that out. There can be relationship issues, so a lot of times there's couple therapy that's involved as well. But then it's also then working through some of their pain issues or talking to a woman about how self-satisfy, how to work with dilators and do different things too but working with the mental health component as well as a physical component. And I think that's so important, and I think for a lot of women as they get older, they've probably had some sexual concerns for 10, 20 years and keep it bottled up. And so, a sexual therapist can often help them investigate that as well. But it's a huge component in managing a lot of these sexual concerns for women of all ages, truthfully.

Erica Newlin, MD:

For sure, and I think even setting aside normal menopausal changes, particularly patients who've had a history of radiation or any health changes or derm issues, in that area, might be helpful to see a sex therapist, just to talk about the changes to their body.

Salena Zanotti, MD:

Exactly. I mean, there's a lot of health conditions, you know, whether you've had a cancer that you had to get treatment for, like we talked about some of those dermatologic conditions for sure that can cause things. And even musculoskeletal injuries that can make it harder for women to do things sexually and so it's addressing those things and then helping a person work through that. And I think it's also important in a lot of situations for the partners to understand what a woman is going through and being a part of it and helping give the woman what she needs and address some of those concerns and so I think that's an important component as well.

Erica Newlin, MD:

For sure. Switching gears, a little bit, does orgasm or ability to orgasm change as we age?

Salena Zanotti, MD:

It can take longer to get an orgasm. Again, because of the changes that are happening in the vagina, there's reduced blood flow to the clitoris and to the muscles and everything there and so women definitely can attain orgasm, it just may be different in how they get there. You know, women may need more manual stimulation or oral stimulation or just different positions, but it'll just take longer and again, it's patience from a partner. And unfortunately, as we get older, a lot of times our partners may have some erectile issues so then you have this catch-22 and I think then it's important to talk to women about using even some vibrators or toys to help because a lot of times doing that before they're sexually active with a man will help arouse them enough so then they both can enjoy it when they're together.

And again, a lot of times, women just need to be told, "It's okay to do this, you know, this is a normal thing you're going through," and so again, giving them suggestions and that's where sex therapists are great too in giving suggestions on ways to help a woman achieve an orgasm too. You know, we don't have great medications or anything that works.

There are, again, some data that shows using some testosterone can help but again, monitoring that. There are some creams out there that women use to help sort of increase the blood flow to the area, and those are things to talk to your provider about.

Erica Newlin, MD:

For sure. I do often warn patients, particularly postmenopausal patients, that any of the stimulating creams that have a lot of kind of cooling or heating effects may be, may be very irritating.

Salena Zanotti, MD:

Yes, yes. You definitely need to tell them that because yeah. A burning vagina's never a good thing.

Erica Newlin, MD:

Yeah. I don't know why that seems to be marketable.

Salena Zanotti, MD:

Yeah, it, people try it though. They do.

Erica Newlin, MD:

Yeah.

Salena Zanotti, MD:

It's funny. Yeah.

Erica Newlin, MD:

And then we've talked about sex therapists and pelvic floor physical therapists, and I think that patients often are taken aback at that idea but I do want to reiterate that that's what their jobs are and that the pelvic floor physical therapists and sex therapists are awesome at getting people comfortable and that it's okay to seek out these resources, so.

Salena Zanotti, MD:

Exactly, you know, and I tell them, you know, "If you have a hip issue or a back issue, you have going to a physical therapist. This is just a part of your body; it's got muscles just like the rest of it and nerves and so it's okay to get help and we have help for it now that really works." So again, it's making women feel comfortable, because you're right. When you bring it up to someone, like first thing, they make a funny face.

Like, "Wait, who's gonna do what? Where are they putting their fingers?" But again, it's just part of our anatomy. And so, we have some really good successful results from these therapists, and I'm glad you're talking about it, so its women knowing this is out there so, you know, you can go ask your provider "I think I'm having these issues. What about a PT consult?" You do that for everything else why not do that for your vagina?

Erica Newlin, MD:

And lastly, are there any books or resources you recommend to patients looking to learn more?

Salena Zanotti, MD:

Yeah, you know, there are a lot of books out there and again, it depends on what are the issues, right? You know, there's an old book, it's been around for a long time, but it's been updated, which is good, and it addresses a lot of different issues for women.

Erica Newlin, MD:

And has great pictures.

Salena Zanotti, MD:

Yeah. Exactly. A lot of these do, they're fun.

Erica Newlin, MD:

Yeah.

Salena Zanotti, MD:

You know, and there's some books that are for men as well to look at, so if you have, you know, sometimes men don't realize what women need. I think if a man's willing to look into that, I think that's great. and all these you can get on Amazon; you know people love Amazon for that kind of stuff.

There's a great website for women, and you go on there and it addresses all the different issues for women, and it has, you know, different therapy options, other women's experiences, and it's very easy to navigate. There's also a website, that's one you subscribe to, but it also gives you a lot of great ideas and different ways to enhance your sexual experiences and so a lot of women find a lot of information there too. But there's a lot more available and again, your provider can also give you more information.

Erica Newlin, MD:

There's a lot of different resources.

Salena Zanotti, MD:

Yeah, there definitely are. And when you have your older women, talking about apps, I had one patient who she didn't even know how to, you know, download an app, so we spent some time and just showed her how to you know, put an app on her phone and so it's again giving them those resources and helping them figure it out.

Erica Newlin, MD:

Mm-hmm. And like you said, a lot of this is normalizing that these issues are okay to address.

Salena Zanotti, MD:

Exactly.

Erica Newlin, MD:

Yeah.

Salena Zanotti, MD:

You know, and I think especially as a gynecologist, when we see women who maybe are widowed or divorced and they haven't been sexually active in five, 10 years and they want to be and they want to go meet people and they're embarrassed to say that and I think again, it's bringing it up, something to discuss, talking about it openly and telling them, "It's okay you want to and this is what we can do to help you," because there are ways to help women enjoy intercourse and any kind of sexual experience, and I think that's what's really important for women to realize now.

Erica Newlin, MD:

And you kind of alluded to this before but when you do have new partners or start enjoying sex a lot more, making sure that you're protecting yourself against STDs and getting regular testing.

Salena Zanotti, MD:

Yes, you cannot get pregnant, but you can get STDs at any age, and we definitely see a rise in certain areas where there are more retired people. So, yes. That's very important, you know, to make sure your partner's been tested and you've been tested if you're not gonna use a condom, but again, using one if it is a new partner.

Erica Newlin, MD:

Well, great. Anything else you'd like to add?

Salena Zanotti, MD:

No, I think you've covered all the topics. This is great and it's an important topic and hopefully women will want to talk about this more.

Erica Newlin, MD:

Well, thanks so much for joining us.

Salena Zanotti, MD:

Thank you.

Erica Newlin, MD:

Thank you for listening to this episode of Ob/Gyn Time. We hope you enjoyed the podcast. To make sure you never miss an episode, subscribe wherever you get your podcast or visit clevelandclinic.org/obgyntime.