Online Health Chat with Dr. Margery Gass
July 23, 2010
Cleveland_Clinic_Host: Female sexual dysfunction is more common than you might think. Several population-based surveys show that approximately 43 percent of American women have some form of sexual dysfunction, from low desire to painful intercourse. In postmenopausal women, several factors can contribute to a less-than-fulfilling sex life. Declining estrogen levels associated with menopause can lead to decreased arousal. The testosterone so vital to male libido is also present in women; the gradual decline in testosterone levels with age may affect female libido. And vaginal dryness — common in post-menopausal women — can make intercourse painful.
An internationally recognized leader in the field of menopause, Margery Gass, MD, is the Executive Director Designate of The North American Menopause Society (NAMS). On January 1, 2010, she also assumes the position of Editor of the NAMS journal Menopause. Prior to accepting these new positions, Dr. Gass was Professor of Clinical Obstetrics and Gynecology at the University Of Cincinnati College Of Medicine where she was also Director of the Menopause and Osteoporosis Center.
Dr. Gass recalls, “Before medical school, I helped organize a support group of mothers with young children who met to discuss medical topics of interest to women. I chose the topic of menopause and that turned out to be a turning point in my life. At nearly 30 years of age, I returned to school to obtain a medical degree. In those years, women were not really included in making decisions regarding their health care; the style then was for physicians to tell patients what to do. I saw entering the medical profession as a way to change healthcare to a more collaborative model.” She believes a woman’s feelings and goals are especially important in the field of sexual health.
Dr. Gass has been an investigator on many research projects and has published and presented on a wide range of topics including menopause, sexual function, hormone therapy, and osteoporosis. She has authored numerous articles and book chapters on menopause-related areas and co-edited a book on managing perimenopause. Dr. Gass served on the NAMS Board of Trustees and served as President in 2002. She played an important part in the creation of the Society’s Certified Menopause Practitioner examination.
Dr. Gass serves on the Advisory Council for the National Institutes of Health (NIH) National Center for Complementary and Alternative Medicine. She also serves as a member of the NIH Advisory Committee for the Office of Research on Women’s Health. She has been an invited speaker at the Amsterdam biannual menopause meeting, the International Menopause Society triennial meeting in Buenos Aires, and the Japan Menopause Society meeting in Tokyo.
Through her clinical practice, research endeavors, academic life, and her new position at NAMS, Dr. Gass has enjoyed working toward improving women’s health and quality of life.
Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. Margery Gass. We are thrilled to have her here today for this chat. Let’s begin with the questions.
Overview of Female Sexual Dysfunction
hope: What is sexual dysfunction in women? Is it age related?
Speaker_-_Dr__Margery_Gass: One definition of sexual dysfunction is any aspect of your sexual function that causes you concern and distress. Sexual dysfunction can happen at any age. The causes are likely to be different at different ages.
sally: What causes sexual dysfunction?
Speaker_-_Dr__Margery_Gass: Many things can cause problems in your sex life. Certain medicines (such as oral contraceptives, high blood pressure medications, and chemotherapy drugs), diseases (such as diabetes or high blood pressure), excessive alcohol use or vaginal infections can cause sexual problems. Depression and, unfortunately, some antidepressant medications can cause sexual problems.
sami: In my early 50s, sex still okay, but takes a lot more work and a lot more time to get there. Does it keep getting worse the older we get?
Speaker_-_Dr__Margery_Gass: It is common for both men and women to experience slower sexual response with aging. Fantasies and adding variety to the sex repertoire (different positions, sex toys, vibrators) can be helpful. Some people take advantage of slowing down to enjoy the intimacy even more.
Signs & Symptoms of Sexual Dysfunction
stu4: Are there signs and symptoms of sexual dysfunction in women?
Speaker_-_Dr__Margery_Gass: The signs and symptoms are generally feelings by the person that their sex life is not normal or the way they want it to be. Feelings could be anything from painful intercourse to no interest in sex.
jumpingjack: Lately I have vaginal dryness (I am 42). I use a lubricant, but intercourse is not as satisfying. What else can I do besides using the lubricant?
Speaker_-_Dr__Margery_Gass: Unfortunately, more information is needed regarding satisfaction. Lack of orgasm? Discomfort? Other issues?
If it is just dryness that is the issue, the addition of a moisturizer used regularly a couple times a week (not at the time of intercourse) may be helpful.
Diagnosing Sexual Dysfunction in Women
sally: How is female sexual dysfunction diagnosed?
Speaker_-_Dr__Margery_Gass: The doctor likely will begin with a thorough history of the problem and your symptoms and then a physical exam. The doctor may perform a pelvic examination to evaluate the health of the reproductive organs and a Pap test (if you are due for one) to detect changes in the cells of the cervix (to check for cancer or a pre-cancerous condition). He or she may order other diagnostic tests to rule out any medical problems that may be contributing to the dysfunction.
Your feelings about sex, as well as other possible contributing factors (fear, anxiety, past sexual trauma/abuse, relationship problems, alcohol or drug abuse, etc.) will help the doctor understand the underlying cause of the problem and make appropriate recommendations for treatment.
If problems persist, find a sex therapist. Sex therapists are thoroughly trained to help people with sexual concerns. They can help with communication problems in the relationship, lack of sexual stimulation by the woman's partner, and many other issues. If you do not know of one and your clinician cannot recommend one, search for a certified sex therapist on the web: www.aasect.org/directory.asp
gwaltney: Is a uterine prolapse common in women over 50 and does this affect sexual function.
Speaker_-_Dr__Margery_Gass: Uterine prolapse is very common. It has no effect on sexual function, unless the woman feels embarrassed by it. The uterus can always be gently pushed further up and out of the way.
Sexual Desire vs. Loss of Interest
southerncross: After my third child, I have lost all sexual desire. I still have sex with my husband, but I do not enjoy it. I never initiate it and my husband is becoming more and more bothered by it. Is this a result of childbirth? What can I do about it? To be honest, I miss ‘enjoying’ the intimacy with my husband.
Speaker_-_Dr__Margery_Gass: It is common for women to have some decreased desire during pregnancy, immediately postpartum and sometimes with breastfeeding, but desire generally returns to normal with time. If it persists, other causes should be considered.
There is a difference between lack of desire and enjoying sex. Commonly women without desire can still enjoy sex once they get into it - especially if they are able to reach orgasm. If the cause of lack of enjoyment or desire is not apparent to you, consider seeing a sex or marital therapist.
alliecat: If you pretty much lost your sexual desire in your 30’s and 40’s – how can it improve after menopause? Is there any hope?
Speaker_-_Dr__Margery_Gass: That really depends on the reason for the loss of interest. For example, causes may be situational or relationship related. If the situation or relationship improves, sexual desire would likely improve.
flippinghot: I cannot take estrogen for menopause because I had an estrogen related cancer and hysterectomy. Besides lubricants for dryness, what can I take to increase sexual desire?
Speaker_-_Dr__Margery_Gass: Currently there are no approved medications for sexual desire. Making sure that intercourse is comfortable with lubricants and moisturizers (there is a difference between the two) is a first step. Try to assess what is keeping you from being interested. Stress, fatigue, issues in the relationship, sexual boredom can all be factors. It has been proven that reading erotic material a couple times a week can increase woman's interest in sex. Sometimes a testosterone level can be checked, but results do not always correlate with level of desire.
powers: Can taking birth control pills for a long time cause a loss in sexual desire?
Speaker_-_Dr__Margery_Gass: Oral contraceptives have been known to decrease desire. However, it is always important to know if desire is decreased for some other reason before discontinuing a reliable form of contraception.
noname: What can increase my sexual arousal?
Speaker_-_Dr__Margery_Gass: One of the symptoms of decreased sexual arousal in women, is a reduced amount of vaginal lubrication. Over-the-counter vaginal lubricants can augment lubrication.
If the decrease in vaginal lubrication resulted from menopause, vaginal estrogen therapy can help. This is the only approved prescription drug therapy for this condition.
The best resource for arousal is our brain. Being on very pleasant terms with your partner and thinking sexual thoughts are two important components for getting aroused. Think about what you find arousing. Make a mental list. How can those things be incorporated into your lovemaking? If thoughts and feelings are not enough, there are many lubricants and sex toys available to explore.
butterfly: I get sexually aroused and foreplay is satisfying. However, ‘penetration’ is not satisfying and can be painful. What could be wrong with me?
Speaker_-_Dr__Margery_Gass: There are several vulvar conditions that contribute to painful intercourse. This requires an examination to know which syndrome a woman has.
jojo: I am in my early 20’s and sex embarrasses me. I get aroused, but as things progress, I feel more and more uncomfortable and am unable to continue. How can I overcome this?
Speaker_-_Dr__Margery_Gass: I recommend discussing this with a physician or clinician with whom you are comfortable. Try thinking back to the past about any memories or things that were said to you that might make you feel this way. If your clinician is not able to help you, ask for a referral to a sex therapist or search for one on the web as described above. It is worth your time and effort so that you can enjoy your relationship.
partyon: I can orgasm through masturbation and with my husband (pardon my being blunt) with his hands or tongue, but never during intercourse. What can I do to change this?
Speaker_-_Dr__Margery_Gass: The majority of women have an orgasm more easily with direct stimulation to the clitoris. There are many women who do not have a so-called 'vaginal orgasm'. It is NORMAL. That being said, in some positions women can arrange to have direct stimulation to the clitoris while the penis is in the vagina, and others find increased stimulation having intercourse with the man behind the woman. Women should not feel as though they need to strive for a vaginal organism It is perfectly normal to reach orgasm other ways.
Pain During Sex
smoggyLA: I have pain during sex. What is this caused from?
Speaker_-_Dr__Margery_Gass: Painful intercourse can be caused by a number of problems, including endometriosis, a pelvic mass, ovarian cysts, vaginitis, vaginal dryness, the presence of scar tissue from surgery, or a sexually transmitted disease. Hypersensitivity around the entrance to the vagina is a common problem that does not necessarily improve with lubrication.
This condition needs to be evaluated by a clinician. Be sure to inform the clinician about the details of the problem – when it first started, how often it happens, what makes it worse or better, and any other important details.
Menopause & Sexual Function
Angel: How do hormones affect female sexual function at menopause?
Speaker_-_Dr__Margery_Gass: Hormones play an important role in sexual function in women. With the decrease in the female hormone estrogen that is related to aging and menopause, many women experience some changes in sexual function as they age, including decreased vaginal lubrication and sometimes decreased genital sensation.
Further, research suggests that low levels of the male hormone testosterone may contribute to a decline in sexual arousal, genital sensation, and orgasm. Researchers still are investigating the benefits and risks of the use of male hormones in women.
If a woman wants to maintain sexual function after menopause, it is important to continue sexual activity. Most women who continue sexual activity through the menopause transition do fine with sexual function even without using any hormone therapy.
eddy: Will menopause decrease my sexual activity?
Speaker_-_Dr__Margery_Gass: Menopause does not have to decrease your sex life at all. It all depends on how you are feeling and what you are thinking. If you are experiencing a lot of stress, anxiety and moodiness, you may not feel very sexy. Emotional changes that often accompany menopause can add to a woman's loss of interest in sex and/or ability to become aroused. Treatments used for PMS can be helpful in these circumstances, and hormone therapy (HT) can also be helpful - especially when hot flashes are bothersome. Hormone therapy and vaginal lubricants may also improve certain conditions, such as loss of vaginal lubrication that is common at menopause.
It should be noted that some post-menopausal women report an increase in sexual satisfaction. This may be due to decreased anxiety over getting pregnant. In addition, women may have greater freedom at home with the children gone from the house, allowing them to relax and enjoy spontaneous intimacy with their partners anywhere in the home.
laura: If I decide to take HT – will this take care of the side effects of menopause including decreased desire?
Speaker_-_Dr__Margery_Gass: Estrogen is not considered a hormone of desire. If lack of interest in sex is due to discomfort or dryness with intercourse, estrogen could improve comfort with intercourse and indirectly increase desire.
The Effect of Hysterectomies & Sexual Function
nikki: Is sexual desire harder after you have had a total hysterectomy with ovaries removed and everything? Is it only related to decreased hormones or other things?
Speaker_-_Dr__Margery_Gass: Desire is mostly related to other things besides hormones. Most women do not have difficulty with desire after a hysterectomy with ovaries removed, other than the fact that it will put pre-menopausal women into instant menopause, and they will have to deal with those symptoms. It may require a psychological adjustment if the woman is particularly young and not expecting to be in menopause at that age.
tarboys: With my hysterectomy, my doctor referred to an area called the vaginal vault and that it was shortened when the roof of the vagina was closed. How is this going to affect intercourse with my husband? Will he not be able to penetrate or what?
Speaker_-_Dr__Margery_Gass: Whether your husband can penetrate will depend on how long the vagina currently is. Your physician should tell you when it is all right to have intercourse and penetration should be approached gently until you determine you are comfortable. If your husband is not able to penetrate completely the vagina may be considerably shorter. You or your husband may be able to determine the length with your fingers. If it is short, check with your clinician about the possibility of gentle stretching with a soft dilator after it is completely healed.
pudgy: If a woman has a hysterectomy in her 20’s or 30’s – does this have the same effect as if the woman is in her 50’s? Will sexual desire come back easier?
Speaker_-_Dr__Margery_Gass: If only the uterus is removed, it should have no effect on desire. If the ovaries are removed, the younger woman has to deal with a very early menopause which requires a psychological adjustment. Sexual desire is related more to relationships than it is to hormones.
sally: Can I take medication to help?
Speaker_-_Dr__Margery_Gass: Taking medication is usually not necessary. The important thing is to sort out why you are not pleased with your sex life. As mentioned above, there are many possible causes.
Treatment will vary depending on the cause. For example, for women who are experiencing vaginal dryness, lubricants, moisturizers and vaginal estrogen are 3 different approaches to getting improvement.
If you have gone through menopause or have had your uterus and/or ovaries removed, taking hormone therapy may help with both hot flashes and vaginal dryness. There are some reasons why certain women should not take estrogen, so ask your clinician if estrogen is an option for you.
You may have heard that taking sildenafil (Viagra) or the male hormone testosterone can help women with sexual problems. Viagra is a medication that improves blood flow to the genitalia, so it has the potential to improve genital arousal and moisture. Studies done with women were not convincing. It is not a treatment for low desire.
There have been a few studies on the effects of testosterone and other drugs on women with low libido. One testosterone patch was approved in Europe, but not in the United States. Testosterone has potential side effects so any use of it should aim toward keeping the blood level in the normal female range.
prodo: Is there a ‘Viagra’ for women?
Speaker_-_Dr__Margery_Gass: There is no Viagra for women. Viagra is a medication that increases blood flow to the genitals which may improve genital arousal (such as penile erection) and lubrication but studies in women were not convincing. Mental arousal and genital arousal is not the same thing. Women can feel mentally and emotionally aroused without genital arousal, so the two do not correlate well. Viagra is not a treatment for low desire.
mmleinnh: I am a relatively healthy, post-menopausal 55 YO woman who has had bilateral knee replacement and several revision surgeries in the last 2 years. Because of pain, I take narcotic medication daily. Can these narcotics and anti-inflammatory medication affect sex drive/interest?
Speaker_-_Dr__Margery_Gass: Yes - pain medications have been reported to decrease libido. However, chronic pain can also decrease libido. It is a challenging situation.
jessiesgirl: My wife is on Prozac and has an almost nonexistent libido. How do you know if this is due to the depression or the drug? What can we do?
Speaker_-_Dr__Margery_Gass: Both depression and anti-depressants are known to decrease sexual function. Some people try switching to another anti-depressant to see if it helps. There are reports that Wellbutrin has fewer sexual side effects.
What is Pelvic Floor Therapy?
Melody: What is involved with pelvic floor rehab? Does it help with painful intercourse? Is it just for post hysterectomy?
Speaker_-_Dr__Margery_Gass: Pelvic floor rehab is an exciting, relatively new field. It is used for a variety of conditions and has been particularly helpful for situations involving pelvic pain and painful intercourse.
Typically the pelvic floor therapist will place monitoring electrodes (painless) on different muscle groups of the vagina, demonstrate to the woman the various muscle group contractions and help her learn how to exercise those groups of muscle. These exercises can increase muscle tone or decrease muscle tone depending on what is needed. Many women experience good results with these programs.
Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Margery Gass is now over. Thank you again Dr. Gass for taking the time to answer our questions about female sexual dysfunction.
Speaker_-_Dr__Margery_Gass: You are welcome. Thanks to everyone for joining our chat. I hope this information has been helpful.
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