Everything you need to know about menopause and sex.
As part of our Lunch & Learn webinar series we were joined by Dr Claire Macaulay of The Pleasure Possibility.
Henpicked: Why is sex an issue people don’t talk about?
Dr Claire Macaulay: People don’t talk about sex in general. And when things aren’t going well we think it’s just us so we’re even less inclined to talk about it. But up to 70% of people experiencing menopause will have some kind of issue. Vaginal dryness is very common, along with loss of sensation or ability to orgasm, as well as issues around desire and libido. My aim is to create spaces for people to have these conversations so they can see they’re not alone.
Henpicked: What’s going on in our bodies to cause these issues?
Dr Claire Macaulay: We have a whole ‘pelvic bowl’ which can be affected. We have outer and inner labia, vagina and clitoris, bladder and pelvic floor to consider. These all contain tissues which require oestrogen to function optimally. If our ovaries are no longer making oestrogen, which happens at menopause, these tissues are not likely to function in the way they did before. As we start to lose tissue we could experience genitourinary syndrome of menopause, which we used to call vaginal atrophy. These tissues start to age and can’t function in the same way. Our vagina doesn’t secrete lubrication, the tissues in our clitoris and vulva don’t work in same way, and we can lose sensation. Sometimes we also start to notice incontinence and urinary tract infections.
But it’s not purely hormonally driven. It would be more easily sorted if so. The way we feel about ourselves and our changing bodies and the level of stress we’re under all feed into how we feel about our sexuality and how we express ourselves.
Henpicked: When can these changes start to happen?
Dr Claire Macaulay: Sometimes the first sign you might notice is vaginal dryness. Maybe not at the atrophy end of things, but not quite as juicy as before. But we often only often realise this in retrospect when we notice other symptoms.
The important thing to understand about this aspect of menopause is that it doesn’t get better with time. With other symptoms like night sweats and hot flushes we can come out the other side and they may settle. But issues about oestrogen depletion in the vulva will not get better with time. The more tissue loss we experience and the longer and longer we go, the more difficult it can be to row back and get some of that function back. So it’s good to be aware of what might be going on so you can make informed decision.
Henpicked: What other symptoms might we notice?
Dr Claire Macaulay: A very common one I hear all the time is about loss of libido, that we just don’t appear to be as interested in sex as we were before. Related issues are loss of sensation, which can translate into lack of arousal, lack of orgasm or orgasms that don’t feel the same. I
Any aspect of change you think you’re noticing is probably real. And understanding it as part of your menopausal transition can allow you to make choices. This awareness allows us to look at the options around what we want to untangle and what we want to do about it.
Henpicked: Sexual expression is very individual isn’t it?
Dr Claire Macaulay: Yes and that’s so key. Menopause is not the time to be putting extra pressure on yourself and thinking you ‘should’ be doing something else. My way of looking at this is that whatever your sexual expression is, it’s about choosing. If you’re choosing or not choosing to be expressing yourself in a certain way that’s fine. This isn’t just about a man and a woman. Lesbians, non binary people, trans men and intersex people can all experience menopause or hormonal shifts.
Irrespective of gender, sexuality, who you’re attracted to or if you’re asexual and don’t want to have sex at all – it’s about what you choose.
Henpicked: Lots of people think sex is finished post menopause. But that’s not true, is it?
Dr Claire Macaulay: If you choose to keep having sex your whole life, it’s possible. We have to be alive to the possibility something is available if we want it. If you want to shut the doors on sex that’s fine. But it doesn’t have to be that way if you don’t want it to.
Henpicked: What can an individual do if they’re experiencing any symptoms?
Dr Claire Macaulay: The more wide-angled view, is to ask yourself ‘what is it that I want?’ I often find with people at this time of life they are so used to managing a family and a job and so on they’ve forgotten to put their own needs first.
In terms of practicalities, if we think about vaginal dryness, there are hormonal ways and non-hormonal ways to treat this. HRT may in itself help. But 25% of women who use HRT still have vaginal dryness. You can use a localised oestrogen cream, a ring or pessary. This can replace oestrogen in the whole pelvic bowl I mentioned earlier. It doesn’t enter the bloodstream in the same way as full HRT, so if you’ve been told you can’t take HRT you should still be able to take vaginal oestrogen.
This can also help with incontinence issues and help with orgasm, as tissues that are beginning to die off will stop doing so.
Non hormonal treatment includes using a long-acting moisturiser for the vagina two or three times a week. This contains a special kind of gel that helps to hold moisture. You can use this alongside hormonal treatment if you want to.
The other thing to think about is moisturising using any edible oil to moisturise the vulva and vagina. Things like coconut oil and olive oil – but don’t use these with condoms. If you are having penetrative sex use tons of lube. Some are specifically designed for menopause. In my opinion, you can never have too much lube!
Henpicked: How do we get hormonal cream – is this available on prescription?
Dr Claire Macaulay: Yes, you need a prescription as you can’t buy the hormonal versions over the counter. But I’d advise anyone who’s having issues with these kind of symptoms to speak with their GP. There are different preparations of vaginal oestrogen and different things to try. Really, there’s very little to lose. And if you need to, you can use it alongside HRT. Some people worry the oestrogen will be ‘passed on’ to their partner during sex but there’s no evidence of this. And it’s not to be confused with lube, which you would apply directly before sex.
One of the things to understand with this treatment is it will work while you take it and will stop when you stop using it. Use for two or three weeks every day then drop to a few times a week. It’s a long-term investment in your genital health.
Non hormonal products can be bought over the counter or are available on prescription from your GP.
Henpicked: Any other suggestions?
Dr Claire Macaulay: There’s reasonably good evidence that when we start to lose sensation we can train that sensation to a certain degree using sex toys. These could be vibratory, or a particularly good one is a clitoral suction toy. To an extent it’s use it or lose it at this point in our lives so this type of ‘training’ can help. Try not to chase orgasm. No orgasm occurs from being chased. But think about what feels pleasurable, slowing down, trying new things. And a date night never goes amiss. Talk to your partner about what works or what you’d like to try.
Henpicked: Is there anything we should watch out for?
Dr Claire Macaulay: If you notice any bleeding after sex you need to see your GP. It may turn out to be atrophy, but we need to rule other things out first. Pain should also be investigated by your GP, or a pelvic floor physiotherapist can help.
Henpicked: What about for those in new relationships after a long time. Any advice?
Dr Claire Macaulay: Nothing is too late. Choosing and deciding to do something is as important as actual products. But you can start trying the oestrogen treatments whenever you choose.
Desire and sex drive is the biggest myth we’ve been sold about sexuality. It’s based on a male-centric view and is very different for women. The vast majority of women don’t experience spontaneous desire, where you’re doing the dishes and you suddenly want sex.
But most women experience responsive desire, once it begins it builds. So don’t expect to be hit out of the blue. Sexuality and expression is something you’re choosing, not just sex itself. Make a commitment to showing up for sex, as once you get started you’re likely to want to continue.
Henpicked’s Deborah Garlick was joined by Dr Claire Macaulay.
Claire is an oncology doctor who treats people with breast cancer. She is also a sex science geek who is passionate about supporting people to create the kind of sex life that is right for them. Throwing away ideas of what people “should” be doing, Claire concentrates on what is meaningful and nourishing to each individual.
Drawing on modalities as widespread as neo-tantra, orgasmic yoga (yes that’s a thing!), somatic sexology and erotic intelligence alongside practical science and research, Claire brings her own blend of compassion, fun and pragmatism to create sex positive spaces where people feel safe to explore and thrive.
Claire has a particular interest in working with people who are in the perimenopausal or menopausal phase of life, whether naturally occurring or as a consequence of medical treatment. Claire works with clients 1:1 or in group coaching programmes, delivers training to healthcare professionals on matters of sexuality and loves nothing more than speaking in public about all things sex.