Menopause

MENOPAUSE

Menopause is defined as a mature woman not having a period for one year. The average age of women entering menopause in North America is 51.2 years. Most women will spend more than a third of their lives in menopause. For many, this is a fulfilling time in their lives, as they are relieved from dealing with menstruation and fears of pregnancy; while for some it means dealing with a new set of symptoms.

Menopause occurs at a time of transition in women's lives. Children are usually grown and living independently. However, there is often an increased level of responsibility and stress related to caring for aging parents. It is a time of change that can redefine partners' intimate roles in what has become an empty nest. This provides both opportunities for personal growth due to the freeing up of child-care responsibilities, but may also unmask previously avoided tensions in the relationship. These psychosocial variables profoundly affect a woman's perception of her passage through menopause.

Seventy percent of women have only a few, time-limited symptoms going through menopause. The remainder suffer to varying degrees from hot flushes, sweats, mood swings, fatigue, weight gain, vaginal dryness, pain with intercourse, and loss of sexual desire. Menopausal loss of estrogen increases the future risk of osteoporosis and coronary artery disease.

The physiological basis for menopause

The effects of menopause are due to the loss of hormone production by the ovaries. Besides producing eggs over a woman's reproductive life span, the ovaries are also responsible for producing most of a woman's estrogen ("female" hormones) as well as half of her androgens, including testosterone ("male" hormones). Most symptoms of menopause are due to the loss of estrogen, though increasing attention is being paid to the effects of the loss of androgen production.

Menopause is not one moment in time, but rather a process called perimenopause that evolves over three to five years before the cessation of menses. During this time a woman's ovaries gradually become less responsive to stimulation from the central control of the pituitary gland at the base of the brain. Over this time, menstrual periods become gradually more irregular, both in timing and in flow. The pituitary gland at the base of the brain responds to circulating estrogen levels and the brain's hypothalamic stimulation by increasing secretion of luteinizing hormone (LH) and follicle stimulating hormone (FSH). Elevated levels of FSH are the cause of hot flushes.

Premenopausal women who have both ovaries removed, usually as part of a hysterectomy and bilateral oophorectomy, have a precipitous decline in their hormones and are suddenly thrust into the symptoms of menopause. The loss of ovarian function causes an 80 percent decrease in estrogen levels. The low levels remaining are produced by the adrenal glands, as well as by peripheral conversion of cholesterol to estrogen in the skin.

Estrogen has effects on many tissues in the body, especially the mucosal lining of the vagina. As estrogen levels drop, this lining thins, produces less lubrication, and becomes more vulnerable to trauma. The urethra is also affected by this increasing the chances of bladder infection and incontinence.

Ovarian testosterone production drops by half, starting as much as three years before a woman's final period. This decline can adversely affect overall mood and energy, as well contribute to decreased sexual desire. The ratio of androgens to estrogen can flip to androgen excess for some women, contributing to increases in hair growth in such "male" areas as the upper lip and chin.

Sexuality during menopause

Menopause frees a woman's sexuality from fear of pregnancy. Up to 70 percent of women note no effects of menopause on their sexuality. These women are more likely to be in mature relationships and have worked through relationship issues that can otherwise confound sexual intimacy. Women who have previously had an active, comfortable sex life tend to have fewer problems with post-menopausal sexuality. The stimulation of intercourse helps keeps the vaginal mucosa thickened and more youthful, supporting the old adage of "Use it or lose it." Cultural values may also play a role in how menopause affects sexuality. In societies where the elderly are more likely to be respected for their wisdom, such as in Japan, most women make the transition through menopause with far fewer symptoms than women in the West.

The most common change in sexual function in menopause is decreased vaginal lubrication in response to sexual stimulation. This loss of arousal can lead to sexual pain, reduced orgasmic intensity, and, ultimately, in decreased desire. Much of this can be helped by taking replacement estrogen. Desire and orgasmic capacity can drop on their own as a result of menopause, independent of any pain or discomfort. Many women loose the sense of sexual passion. These changes can be due to decreased testosterone.

The menopausal woman is not the only one going through changes at this point in her life. Married women's husbands are dealing with their own physical changes. The slowing of the sexual response allows many couples to savour their sexual interaction, in contrast to the mad rush of youth. While it takes longer for both men and women to get aroused, lovemaking can last longer due to the aging male's decreased pressure for orgasm. Indeed, many older men do not need to ejaculate in order to enjoy the sexual experience. For most, this is an enjoyable experience. For some couples, however, not understanding the physical changes that go with aging creates concerns. Some women, having been used to a stronger sexual response from their partner, personalize these changes and wonder if they are no longer seen as attractive by their mate, or if he is having an affair. This often increases the pressure to perform that is already worrying the man, who may be wondering if he is developing impotence.

When women have sexual dysfunction, about half of their partners will also have sexual difficulties of their own. Women who have no sexual difficulties may still have to deal with their partner's loss of potency. Male erectile dysfunction increases with age, with complete loss of erection occurring in 5 percent of men at forty, and increasing to 15 percent by age seventy. More than half of older men have some partial degree of erectile dysfunction that interferes with sexual intercourse. Most erectile dysfunction in men is not due to hormonal changes, but rather to aging of blood vessels and the mechanisms that increase the blood flow to the penis. The revolution brought about by Viagra™ and other therapies can often help men and women dealing with these difficulties.

Men also appear to go through a male menopause. In contrast to women, men have a more gradual decline in their own testosterone, starting in the late forties and continuing over the next two to three decades. This results in similar changes seen in women, including decreased desire and orgasmic drive, and ultimately in the loss of erections.

Many women become single, either through widowhood or divorce, in the years following menopause. For many this leaves them to deal with their sexual needs alone. Women who reenter the world of dating and becoming sexual with a new partner face a number of concerns. The vaginal changes of menopause leading to atrophy and loss of elasticity progress more quickly if a women is not sexually active. If a woman has not had a partner for a long time, she is at increased risk of having discomfort. This can usually be treated with local estrogen. Many physicians desexualize their older female patients and do not think to counsel them about safe sex. Many older women are not conscious of the risks of sexually transmitted disease in this population. The thinner vaginal walls are more vulnerable to infection with intercourse. While numbers are still small, the greatest rate of increase in HIV/AIDS is in women over fifty.

Women in menopause are aging and may have other medical illnesses that can affect sexual function. Hypertension, diabetes, depression, and heart disease are but a few examples that can have profound effects on sexual function. The drugs used to treat these conditions frequently have sexual side-effects as well. Antidepressants commonly cause sexual difficulties, decreasing desire, arousal, and orgasm for both women and men.

Many sexual concerns during menopause are not related to hormonal changes at all. Sexual behavior involves an interaction between two people. Women are generally more sensitive to the context and connection they feel within the relationship than men are, and sexual dysfunctions are often symptomatic of other stresses, either on an individual or a couple. Sex can deteriorate due to psychological problems for either partner, or due to relationship strains. Effective treatment of sexual concerns needs to take into account the physical and psychological health of both partners, as well as the state of their relationship both inside and outside of the bedroom.

Estrogen replacement/hormonereplacement therapy (HRT) and androgen replacement

The loss of estrogen affects more than the reproductive organs. Decreased estrogen leads to increased bone loss and the risk of osteoporosis, with concerns about hip and vertebral fractures. The protection that estrogen provides premenopausal women against heart attack (relative to men) is also lost in menopause. Skin, in general, becomes thinner and more susceptible to trauma, and thinning of the vaginal mucosa leads to decreased lubrication and potentially painful intercourse. A woman's mood can become more unstable around menopause, with greater mood swings and an increased risk of depression.

The use of hormone replacement therapy (HRT) with estrogen (and progesterone to protect against uterine cancer if the woman still has a uterus), helps prevent and treat vaginal atrophy, as well as providing proven benefits such as osteoporosis prevention. The use of HRT to treat post-menopausal mood problems may help some women previously labeled depressed as much as antidepressants do.

Clinical trials currently underway with estrogen replacement may show benefit in reducing the rate of bowel cancer. Further studies are needed to see if estrogen can prevent the risk of heart attack and coronary heart disease. At this point estrogen does not seem to reduce future heart attacks in women who have already had one.

Women who receive estrogen replacement need to also take progesterone if they still have their uterus. Progesterone is produced along with estrogen in the pre-menopausal woman. It is more active in the second half of the menstrual cycle and maintains the lining of the uterus until levels drop to trigger the next period. Progesterone serves a protective function for the endometrial lining, balancing the stimulating effects of estrogen. Post-menopausal women taking estrogen alone are at increased risk of developing endometrial or uterine cancer. This increased risk is eliminated with the combination use of progesterone with estrogen.

Many women have decreased sexual desire and responsiveness in spite of HRT. This is due to a reduction in testosterone and other androgenic hormones. When women enter menopause, they lose half of their testosterone production when the ovaries stop functioning. While traditionally thought of as a "male" hormone; in reality, men and women have both estrogen and testosterone, just in different ratios. More than half of women with post-menopausal decreased desire will respond positively to testosterone replacement. The potential risks of androgen replacement can include possible virilization, with skin changes such as acne, increased and coarser body hair, deepening of the voice, and enlargement of the clitoris.

Adding replacement testosterone increases women's sexual desire, arousal, and ability to orgasm; as well as nonsexual energy and mood levels. Within a few years, triple hormone therapy with estrogen, testosterone, and progesterone may well become the standard of care.

Effect of HRT on sexual problems

All three stages of the human sexual response cycle (desire, arousal, and orgasm) can be affected by the hormonal changes of menopause.

Sexual desire is mainly modulated by testosterone. Women with decreased desire due to low testosterone respond with increased sexual frequency and improved sexual pleasure. Estrogen contributes in a limited way to desire, primarily by reducing the negative effects of vaginal atrophy. Otherwise, the effects of estrogen on desire are limited. Testosterone replacement for women is a rapidly advancing field, with oral and injectable forms, topical creams, patches, and implantable pellets all being available.

The loss of natural estrogen can lead to vaginal dryness and lack of lubrication, which HRT can help. Estrogen can be given in a number of ways as well, with vaginal cream, oral pills, patches, and injectable medications being available. All have similar effectiveness, although the intravaginal cream provides the most rapid healing for vaginal atrophy.

When given over an extended time, estrogen must be given in combination with progesterone to reduce the risk of uterine cancer. Most women notice little change on their sexuality from progesterone therapy. Those women who have had a hysterectomy do not need to take additional progesterone.

For some women, the use of HRT is generally contraindicated (such as those with advanced breast cancer.) For those women not responding to alternative therapies, local vaginal symptoms can be treated using a soft plastic pessary (Estring™) that is impregnated with estrogen. It is only locally absorbed and is believed to not increase the risk of cancer recurrence.

Many women who loose the intensity, or even the capacity, to orgasm after menopause will benefit from replacement testosterone. This is especially noticeable after surgical menopause (the operative removal of both ovaries, which causes a sudden loss of estrogen). Sexual satisfaction, as well as overall psychological well-being is generally improved by testosterone replacement.

Some women may not be able to take HRT for medical or personal reasons. Nearly half of adults have used alternative therapies in the last year. There is great clinical demand to have more products available to help these women. While there has been an increase in sexual health research, especially for men, there are still many more questions than answers that await study to demonstrate effective therapies for women. Many alternative products exist to try to help women with menopausal, including sexual, concerns. Some of these include phytoestrogens, dong quai, evening primrose oil, black cohosh, and ginkgo biloba. Few of these have been evaluated using placebo-controlled studies, and some have negative side-effects and interactions with other medications. Given the strong psychological effect on sexual function of taking a placebo, these therapies need to be viewed with caution.

Specific products for post-menopausal vaginal dryness include Replens™, which is a longeracting vaginal moisturizer that is inserted into the vagina every few days as needed. This is helpful for nonsexual sensations of vaginal dryness.

Other nonhormonal options that are effective include vaginal artificial lubricants to help with intercourse, such as Astroglide™, Just Silk™ and K-Y™ personal lubricant. All of these are safe to use with condoms. Oil-based products, however, can cause condoms to leak. The use of unscented oils, such as peanut oil and Alpha-Keri Bath Oil™, is also more acceptable than petroleum jelly, which is too sticky.

There are no other aphrodisiacs better than a placebo available to help women have more sexual desire or better orgasms.

Conclusion

Menopause has historically been a time when women were considered to be in the twilight of their lives, and when they were often disregarded in society. Today, however, women are entering menopause healthier and more active than ever before. Recognition that they have many roles to play allows them to have productive lives longer than their mothers and grandmothers. Much of this is due to social change and new perceptions of aging women, especially with respect to how menopausal women look at their sexuality. Medical treatments have been expanding to help reduce the effects of changes in hormonal status, helping maintain energy, well-being and sexual function.

Stephen Holzapfel

See also Andropause; Breast; Depression; Endocrine System; Hair; Osteoporosis; Sexuality; Urinary Incontinence; Urinary Tract Infection.

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