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Sexual Health at Menopause video still

Dr. James Simon discusses the importance of sexual health during menopause and encourages clinicians to open up the conversation with patients. He discusses several treatment options and resources with Dr. Marla Shapiro.

Dr. Marla Shapiro:

Hello, I’m Dr. Marla Shapiro. I’m a past president of the North American Menopause Society and today I’m joined by Dr. Jim Simon, who is also a past president of the North American Menopause Society. For our healthcare practitioners who may not know you, please tell us who you are.

Dr. Jim Simon:

Thank you. I’m happy to be here. I’m Dr. Jim Simon. I’m a reproductive endocrinologist and clinical professor at George Washington University. I’m the immediate past president of the International Society for the Study of Women’s Sexual Health.

Dr. Marla Shapiro:

That’s where we’re going to start today. We’re going to talk about sexual health because often as healthcare practitioners we’re not trained or we’re not comfortable. So, what are some of the most common issues that we see in women in and around menopause and in menopause when it comes to their sexual health?

Dr. Jim Simon:

So, I like to consider this in three different buckets. It makes it easy for me to keep it straight. So as women transition to menopause, it’s very clear that they have vasomotor symptoms, and disturbed sleep. Disturbed sleep has many downstream consequences, two of which are weight gain and that affects one’s self-image, which has an adverse effect typically on sexual interest. The other is fatigue, which clearly affects one’s interest in any kind of extracurricular, shall we say, activity.

Dr. Jim Simon:

Then the other two buckets are sexual pain, which occurs after menopause most commonly and as women approach their 60th year in particular, and loss of sexual desire as women’s hormones synergize with their loss of sleep.

Dr. Marla Shapiro:

So, for many practitioners and even some of our patients, there’s this bias that this is aging. There are often no questions that are asked by the healthcare practitioner, and women often just assume this is the way it is and don’t bring it up as well. So how do we break that barrier and open the door for the conversation?

Dr. Jim Simon:

So, this is a really critical question because patients don’t bring it up and there’s good scientific evidence that they don’t, and practitioners don’t bring it up and there’s good scientific evidence that they don’t bring it up. So, it’s kind of a Mexican standoff, if you will. No one’s talking about it, so it doesn’t get talked about.

Dr. Jim Simon:

The problem is that someone’s got to break the ice and I really think that it’s got to come from patients. We in practice think that there are many more important things to women. Whether that’s true or not for an individual woman is not the least bit clear. But if women will bring it up, then we have an opportunity to jump in or at least be triggered to go to the library, refer the patient, or learn ourselves and intervene.

Dr. Marla Shapiro:

So, let’s talk about what’s new in sexual medicine because for so many years, multiple drugs for men all over television and media giving it the legitimacy to talk about this. But for women, there is this sense that there’s nothing out there. So, what’s there to talk about anyways?

Dr. Jim Simon:

So, there are a couple of very interesting occurrences that have happened in the last year or so in the answer to this question. The first, and I’ll bring it back to Canada, is that the Canadian government, Health Canada approved the use of flibanserin, which is sometimes called the pink pill for women after menopause and up to age 60.

Dr. Jim Simon:

This is a big deal. There’s been data on this for almost a decade now, yet no approval for women after menopause who clearly need it in higher percentages than younger women. So that’s one thing that’s happened in this last year.

Dr. Marla Shapiro:

Aimed to treat low desire.

Dr. Jim Simon:

Correct. Aimed at treating hypoactive sexual desire disorder, which simply put is low sexual interest or absent sexual interest and wanting to fix it. Being distressed about having lost that sexual desire.

Dr. Jim Simon:

The other two things that happened in this last year or so was an international global consensus paper on the importance of testosterone in menopausal women. We know that women lose estrogen at menopause. They lose testosterone from about age 30 on, becoming more of a crisis as they approach age 60. Testosterone is a pivotal and important hormone for women of all ages.

Dr. Jim Simon:

Then lastly, because there are no approved medications in North America for testosterone therapy in women, there are about 30 in the US for men, the International Society for the Study of Women’s Sexual Health with an international group of experts came out with a how to use testosterone in postmenopausal women. So no practitioner should have to be fiddling around trying to figure it out.

Dr. Marla Shapiro:

So where are we going? We now have this position paper with evidence in science, and very clear indications. It’s not one size fits all every postmenopausal woman needs testosterone. We have flibanserin. Has it opened up the door to more investigations, more products for women’s sexual health, and more let’s get it out into the mainstream?

Dr. Jim Simon:

So, in addition, we also have an injectable as desired treatment in the US for low sexual desire called Bremelanotide, or Vyleesi. It’s on the market and available to add to your list.

Dr. Jim Simon:

But I also want to say that for women who either can’t use those products, or have a contraindication to those products, there are a number of products that have let’s say a side effect of stimulating sexual desire, either at the dose that they’re approved for another indication, or either a lower dose or a higher dose than with knowledge can be brought to bear for an individual woman with low sexual desire to boost that desire.

Dr. Marla Shapiro:

And those medications…

Dr. Jim Simon:

So, they fall into medications that typically affect the neurotransmitters in the brain, increasing dopamine and decreasing serotonin. That’s a pro-sexual effect. Medications like Trazodone at very low doses, which can be used for sleep as well as improving sexual desire.

Dr. Jim Simon:

Buspirone, which is usually considered an anti-anxiety agent, is also pro-sexual in many ways. So, a woman who’s anxious about sex and has low desire because of her anxiety could be treated for both with Buspirone. Bupropion, which is an anti-depressant, but at high doses is known to stimulate sexual interest, and arousal and improve orgasm.

Dr. Marla Shapiro:

Well, I want to thank you for joining us because opening up this conversation, lets our healthcare practitioners know that there are options out there, and if you’re unaware of the options, it’s not that difficult to get that education.

Dr. Jim Simon:

Absolutely. Critically important. For those women who cannot find a knowledgeable provider or whose practitioners wish to get additional information, both the North American Menopause Society and the International Society for the Study of Women’s Sexual Health have found provider functions on their websites and both providers and patients can go there to get some help.

Dr. Marla Shapiro:

Thank you so much for joining us today.

Dr. Jim Simon:

My pleasure. Thank you.

 

Dr. James Simon discusses the importance of sexual health at menopause and encourages clinicians to open up the conversation with patients. He reviews treatment options and resources. (www.menopause.org)

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A banana spooning an eggplant with a light pink background.

A banana spooning an eggplant with a light pink background.Is penetration ever painful for you? Whether it’s with fingers, toys, or penises, you’re not alone: An estimated 50% of menopausal women with sexually active partners experience pain during vaginal penetration. And that’s just women in menopause. (Note: Here’s a Partner’s Guide to Menopause)

Dyspareunia is a very general term for pain with penetration during intimate sexual contact. Deep pelvic pain, or deep dyspareunia, usually emerges because of other existing disorders hidden in the pelvis—either adjacent to or touching the upper portions of the vagina.

There are a few different possible causes for this deep pelvic pain (or deep dyspareunia), which include:

  • fibroid tumors in the uterus
  • cysts in the ovaries
  • tumors on the ovaries
  • endometriosis
  • scarring from pelvic infections or prior surgery

While the disorders that we just listed above are relatively common, the deep pelvic pain that can result from them is not nearly as common. Most people with these disorders won’t have the correlating deep pelvic pain, but if you experience a new onset of deep pain during sex, which can be triggered by a new partner or experience, you should talk with a doctor or other health professional.

More common causes of both superficial and deep pelvic pain include:

  • Vaginal atrophy following menopause (AKA vulvovaginal atrophy, genitourinary syndrome of menopause, or GSM)
  • Vestibulodynia (vulvar vestibulitis)
  • Pelvic floor muscle dysfunction

Regardless of the cause, pain during penetration is not fun, and it certainly isn’t comfortable. To provide additional context, this typically happens when there’s any restriction of movement at the opening of, or at the top of the vagina.

The vagina is meant to slide on its neighboring organs (i.e., ovaries, tubes, uterus, intestines, rectum, etc.). When the top of the vagina (or the vaginal apex) is restricted or bumps up against a tender neighboring organ or disorder, like a fibroid or an ovarian cyst, during penetration, it can cause deep pain.

Other relevant factors include:

  • Depth of penetration
  • Sexual position

Let’s do some quick math—Depending on the length and girth of the fingers, penis, or toy that’s penetrating you + the length of your vaginal canal = deep pelvic pain may only occur intermittently, for example, only with sex in particular positions, with a particular partner, or with a particular partner in a particular position.

If you are experiencing deep pelvic pain from penetration, regular or otherwise, a diagnosis can usually be determined with a vaginal or abdominal ultrasound (sonogram). Vaginal ultrasounds are preferred since the probe that’s inserted into the vagina can be used to reproduce or simulate the pain that’s felt during penetrative sex—quickly demonstrating exactly where and how the pain is initiated.

If endometriosis is the cause, there are a couple of things to note:

  1. Endometriosis often goes undiagnosed for many years.
  2. Endometriosis can be difficult to diagnose.
  3. A complete evaluation may require a careful rectal exam; this is because endometriosis causing deep penetrative pain during sex may best be felt on a rectal exam.

Typically, treatment of deep pelvic pain is focused on any underlying disorder. It may be surgical (i.e., fibroids, ovarian cysts, endometriosis, or scarring) or responsive to medication (i.e., fibroids, ovarian cysts, endometriosis).

When surgery isn’t preferred or necessary, there are medical therapies to shrink the size of fibroid tumors and reduce the heavy menstrual bleeding associated with them, and other medical treatments have been developed to shrink endometriosis, and reduce the associated pain, including deep sexual pain. These treatments include oral contraceptives, and both the injectable GnRH agonists (i.e., Leuprolide, Triptorelin) and the oral GnRH antagonists (i.e., Elagolix, Relugolix, Linzagolix). These GnRH modulating drugs are used to temporarily create a menopausal hormone milieu, because menopause typically shrinks these pathologies and clears the way for unrestricted movement of the upper vagina.

Typically, medical approaches are favored initially, and surgery reserved as a last resort. However, exceptions to this rule are common. For example, if fibroid tumors are causing infertility or recurrent miscarriages and there is related deep pelvic pain during penetration, surgery may be the only choice that can address all three problems: the infertility, pregnancy loss, and deep pelvic pain.

Additional remedies include pelvic floor physical therapy, including treatments like trigger point injections and pelvic floor “Botox,” which can be helpful in reducing the reactive pain, and can help your pelvic muscles to unlearn the guarding they do related to these disorders.

A very simple and non-invasive at-home remedy for pain with deep penetration is reducing the depth of penetration. Testing various positions that shorten penetration can help to achieve this, as can the OhNut, a wearable device that allows you to customize the penetration depth of penises and/or toys.

What else have you found to help? Comment with any thoughts, questions, or concerns. Or you can always give us a call to setup a consult.

 

References:

Yong PJ. Deep Dyspareunia in Endometriosis: A Proposed Framework Based on Pain Mechanisms and Genito-Pelvic Pain Penetration Disorder. Sex Med Rev. 2017 Oct;5(4):495-507. doi: 10.1016/j.sxmr.2017.06.005. Epub 2017 Aug 1. PMID: 28778699.

Donnez J, Stratopoulou CA, Dolmans MM. Uterine Adenomyosis: From Disease Pathogenesis to a New Medical Approach Using GnRH Antagonists. Int J Environ Res Public Health. 2021 Sep 22;18(19):9941. doi: 10.3390/ijerph18199941. PMID: 34639243; PMCID: PMC8508387.

Orr N, Wahl K, Joannou A, Hartmann D, Valle L, Yong P; International Society for the Study of Women’s Sexual Health’s (ISSWSH) Special Interest Group on Sexual Pain. Deep Dyspareunia: Review of Pathophysiology and Proposed Future Research Priorities. Sex Med Rev. 2020 Jan;8(1):3-17. doi: 10.1016/j.sxmr.2018.12.007. Epub 2019 Mar 28. PMID: 30928249.

Eid S, Loukas M, Tubbs RS. Clinical anatomy of pelvic pain in women: A Gynecological Perspective. Clin Anat. 2019 Jan;32(1):151-155. doi: 10.1002/ca.23270. Epub 2018 Dec 3. PMID: 30390350.

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Image of couple riding in an orange Thunderbird convertible

Hypoactive sexual desire disorder (HSDD), which affects about 10% of women in the United States, is defined as the persistent or recurrent deficiency or absence of sexual desire accompanied by personal distress. There are treatments to help you deal with these symptoms, and it is possible to regain sexual desire and libido.

Image of couple riding in an orange Thunderbird convertible

Although HSDD impacts patient quality of life and interpersonal relationships, the disorder often goes unaddressed or untreated. Recent studies of the burden of illness in women with HSDD, especially pre-menopausal women, are limited.

I co-authored an article in the Journal of Women’s Health assessing the burdens that women face when they have HSDD, or lack of libido and desire. You can read the highlights of the study here:

Materials and Methods: A 45-minute web-based survey was designed to investigate the experience of women seeking treatment for HSDD and the impact of this disorder on several psycho-social aspects of women’s lives.

Women were recruited from an online panel of patients who participated in research studies for compensation. Validated questionnaires assessed sexual function and health-related quality of life, including mental and physical component scores.

Results: A total of 530 women, aged 18+ years, diagnosed with HSDD were included in the study. Pre-menopausal women indicated greater overall HSDD symptom burden compared with post-menopausal women. Patients with HSDD reported lower quality of life scores compared with the general population.

A multivariable regression analysis demonstrated that psycho-social factors influencing the burden of HSDD, including interference with relationships with their partner, mental and emotional well-being, and household and personal activities, negatively affected quality of life mental component scores.

Conclusions: In the current survey, HSDD had a significant negative impact on sexual and mental health, social relationships, and general well-being. The impact was greater among pre-menopausal women compared with post-menopausal women.

Read the full Journal of Women’s Health article, co-authored by Dr. Simon, here.

And if you’d like to discuss treatments to help you deal with HSDD symptoms, including an increase in sexual desire and libido, you can fill out an appointment request form.

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Three women on the beach pier; they're leaning together and talking.

Three women on the beach pier; they're leaning together and talking.

There is so much misconception about hormone replacement therapy (HRT) and menopause. I was recently featured on #justASK, a healthcare podcast dedicated to providing evidenced-based information from a team of sexual health experts. #justASK is hosted by Tara Thompson and Heather Quaile.

It was great to break down some of those misconceptions, and dive into the importance of hormone replacement therapy, solutions to frustrating peri-menopause and menopause symptoms, and myths and taboos surrounding these topics.

Women’s health has been under-researched and under-funded for way too long, and that’s a large reason why there is such a lack of comprehensive information.

A few notes you’ll hear me address in the podcast:

  • One of the biggest problems around lack of access to hormones is that there’s an entire generation of practitioners (physicians, nurses, PAs) who heard hormones were risky and were never trained to administer HRT. The medical community is finally coming around to addressing this misinformation and are finally being trained to replace hormones safely.
  • Hormones fluctuate throughout our lives. Fun fact: The only time in a woman’s life when her hormones are the same level as they are after menopause is when she’s breastfeeding. In the context of breastfeeding, those low hormone levels are a good thing, whereas it can be incredibly harmful during menopause.
  •  Hormones prevent bone loss, and ultimately prevent fractures. Hormone therapy, and non-hormonal medications, can all help strengthen bones and prevent osteoporosis.
  • There tends to be an increase in sex drive around the middle of a menstrual cycle. These are the same hormones that can stimulate libido during menopause, and we can apply them so that they stimulate the brain and can help increase interest in sex beyond reproductive years.

Listen to the full podcast below, and feel free to comment with any questions. You can also make an appointment to figure out if hormones are right for your body.

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Photograph of older couple cuddling in bed

Photograph of older couple cuddling in bed

How many times have you shuddered the moment someone mentions your parents or your grandparents having sex?

As a doctor specializing in sexual health, I’ve seen that inevitable gasp time and time again.  The mere mention of our parents, or worse, our grandparents, “rolling around in the hay” leads to grimaces followed by an expression of “really!?” “yuck” or “gross”. This reaction is natural in our often times sex-phobic, even puritanical culture, but these attitudes set too many people up for failure. A fear of aging and an inability to associate sex with aging undermines the many health benefits gained simply by continuing sexual activity through our 70s and beyond. These health benefits are often overlooked by healthcare practitioners as well. A recent NYT Magazine article, “The Joys (and Challenges) of Sex After 70” attempts to normalize sex in older adults.

Here are 5 important points we wanted to highlight for you:

  1. People frequently have sex up until the end of their life.
  2. Everything about sex after 70 usually takes longer, is slower, but generally still works.
  3. Sex is so much more than penetration. Too often we are taught that sex is only penis-in-vagina (PIV), but that’s incredibly limited. If PIV is your definition of sex, that may need to change as you age.
  4.  Communication is one of the most critical components when it comes to good sex, especially since pleasure and desire change as we age.
  5. There are effective medications and non-medical treatments for sexual problems related to aging, regardless of your sex or gender.

As men age there are plenty of medications approved to increase their sexual health—we’re sure you’ve heard of Viagra or Cialis? And there are many other brands designed to do the same thing, plus no fewer than 25 different testosterone formulations for men.

For women, on the other hand, there are just two FDA-approved options: Addyi (Flibanserin), and Vyleesi (Bremelanotide). And while they both work for women well beyond menopause, as of right now,  neither of the two have been approved by the FDA for postmenopausal women, simply because FDA requirements have not been satisfied. And while pharmacologic treatments are not for everyone, both Addyi and Vyleesi should work for women of any age. Data on Addyi’s benefits in menopausal women was published almost 8 years ago, and is approved by Health Canada for use in women up to age 60. Many of our patients at IntimMedicine Specialists find it to be beneficial regardless of their age.

It is extremely frustrating that there are currently no testosterone products approved for women’s sexual health in the US. This past year, off label use of male testosterone products and compounded testosterone treatments for women had become so prevalent that the International Society for the Study of Women’s Sexual Health (ISSWSH) developed a manifesto for healthcare practitioners.  This “how to” is a classic citation of safe and effective use of “male” testosterone products in women.

As emphasized in the NYT Magazine article,  people often face many physical challenges in the bedroom as we age. It is normal for bodies to change, and for the ways we access pleasure to shift. For example:

  • Vaginal dryness is a normal shift in the body.
  • Erections are often not as naturally hard, as reliable,  or as long-lasting.
  • Physical movements and positions may become more limited, but that doesn’t mean that adaptive positions can’t be just as pleasurable.

While pharmacologic options can be really helpful, they aren’t for everyone, and there are other resources that can help normalize and troubleshoot sexuality through the aging process. You should check out the following:

Next time you shudder at the mention of your parents or grandparents still enjoying sex, consider the age you want to stop having sex – our guess is that you don’t ever want that. So, if you (or that parent or grandparent) need a little help, let us help identify the problem and offer some solutions for your body (or theirs). We can help, just reach out.

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Pills sitting on pink counter surrounded by caution tape.

Actress Gwyneth Paltrow, founder of the wellness and lifestyle brand goop®, recently launched a new “sexual health supplement” marketed under the name DTF. According to advertisements, this product is intended to “support women’s sexual desire, arousal, and mood.” We believe this claim to be an example of a misleading campaign marketed to consumers that is unsupported by scientific evidence. 

Pills sitting on pink counter surrounded by caution tape.

As a member of the International Society for the Study of Women’s Sexual Health (ISSWSH), which is comprised of leading academics, researchers, clinicians, and educators in female sexuality, IntimMedicine supports and agrees with ISSWSH’s concern around frequent, unsubstantiated claims made about many over-the-counter (OTC) products marketed to women for sexual enhancement. goop®’s latest product, DTF, is one of these products that concerns us.

While we applaud the attempt to investigate herbal ingredients which are in use by consumers, the statement by goop® that the ingredients in DTF are “clinically studied to support female sexual health and function” is egregiously misleading. Here’s why:

According to their own website, DTF “hasn’t been evaluated by the FDA” and “is not intended to diagnose, treat, cure, or prevent.”

According to the goop® website, DTF contains three main ingredients: Libifem®, a fenugreek seed extract, shatavari root extract, and saffron stigma extract. While one small study published in Phytotherapy Research in 2017 appears to support some potential benefit of one ingredient in DTF specifically to women with the vasomotor symptoms of “hot flushes, night sweats and other associated symptoms,” which are typically associated with the menopause, we were unable to find any data to demonstrate safety, efficacy or tolerability of the combination of active ingredients in DTF for women of any age to whom goop® makes these claims on female desire, arousal and mood.

As experts in the sexual health field committed to the highest standards of scientific research and medical care of women’s sexual health, we are not only concerned about the lack of proven benefit from such supplements, but also the potential harm to individuals who choose to take these products.

43% of U.S. women report some type of sexual problem for a multitude of bio-psycho-social reasons.  Lumping all sexual problems together is unlikely to lead to an appropriate treatment and improvement, which is why qualified healthcare providers, like IntimMedicine staff, diagnose a sexual problem before recommending a relevant treatment.

Hypoactive sexual desire disorder (HSDD) is a diagnosable and treatable medical condition experienced by upwards of 10% of U.S. women.  In 2018, ISSWSH published an HSDD process-of-care to assist healthcare providers in the diagnosis and management of pre- and post-menopausal women with HSDD. This open access article is freely available online.

In order to properly address low libido and HSDD, women should avoid self-treating with OTC products, like DTF, without the guidance of a licensed healthcare provider. 

There are two FDA-approved treatment options (flibanserin and bremelanotide) available in the U.S. for pre-menopausal women with acquired, generalized HSDD with extensive safety and efficacy data. Flibanserin is also approved in Canada for pre-menopausal women and naturally post-menopausal women ≤60 years of age.

As a practice that is focused on the advancement of women’s sexual health, it is our mission, alongside ISSWSH, to promote the dissemination of evidence-based information. Women should know that the medical community has treatments approved by regulatory agencies and processes of care to guide their healthcare providers in the delivery of evidence-based medicine.

References

  1. O’Malley, K. Gwyneth Gwyneth Paltrow’s Goop just launched a supplement to boost female libido.
  2. Reilly, K. Do Gwyneth Paltrow’s new ‘DTF’ libido supplements really work? Doctors weigh in.
  3. Sydora BC, Fast H, Campbell S, Yuksel N, Lewis JE, Ross S. Use of the Menopause-Specific Quality of Life (MENQOL) questionnaire in research and clinical practice: a comprehensive scoping review. Menopause 2016;23:1038-1051.
  4. Steels E, Steele ML, Harold M, Coulson S. Efficacy of a proprietary Trigonella foenum‐graecum L. de‐husked seed extract in reducing menopausal symptoms in otherwise healthy women: a double‐blind, randomized, placebo‐controlled study. Phytotherapy Research 2017;31:1316-1322.
  5. Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors. JAMA 1999;281:537-544.
  6. Shifren JL, Monz BU, Russo PA, Segreti A, Johannes CB. Sexual problems and distress in United States women: prevalence and correlates. Obstetrics & Gynecology. 2008;112:970-978.
  7. Brotto LA. The DSM diagnostic criteria for hypoactive sexual desire disorder in women. Archives of Sexual Behavior 2010;39:221-239.
  8. Clayton AH, Goldstein I, Kim NN, Althof SE, Faubion SS, Faught BM, Parish SJ, Simon JA, Vignozzi L, Christiansen K, Davis SR. The International Society for the Study of Women’s Sexual Health process of care for management of hypoactive sexual desire disorder in women. Mayo Clinic Proceedings 2018;93:467-487.

Adapted from ISSWSH’s official statement.

How the US Government and The Media Conspired to Convince Women That Menopausal Hormone Therapy Was Dangerous” presented at ISSWSH 2020 Orlando, FL March 5, 2020

Dr. Simon explains why even doctors need to be educated on menopause.

Check out Dr. Simon’s view on hot flashes.

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