We recently hosted our third Instagram Live session of Bonafide Talks, on the topic of changes in desire, arousal and sexual satisfaction commonly experienced during menopause, featuring Bonafide Chief Medical Officer, Dr. Alyssa Dweck.
During the conversation we covered a variety of topics, including what can influence changes in sexual desire or orgasm during menopause, as well as outside factors that may impact sexual satisfaction and things you can do to improve it. In case you missed it, we’ve included a recording of this third session here, along with a full transcript of the video.
Stay tuned for more Instagram Live sessions!
Sarah: Hi, everyone. Thanks so much for joining our third informational session of Bonafide Talks. This is our IG Live series, featuring our Chief Medical Officer, Dr. Alyssa Dweck, who is a practicing gynecologist, with over 25 years’ experience, and of course, our Chief Medical Officer.
So, if this is your first Live, welcome, and thanks for joining us! In the previous sessions, we talked about vaginal dryness and hot flashes. And the focus of today is going to be changes in sexual satisfaction that occur during perimenopause and menopause, specifically focusing on sex drive and orgasm.
Just a reminder that our previous sessions are available, we’ve recorded them, so they're available to review on Instagram, or Facebook or on our blog. So, go check those out whenever you have the chance. And as a note, this session today will also be recorded – it'll be available after the live. So, we're good to get started. Thank you again for joining us, Dr. Dweck.
Dr. Dweck: It is my pleasure to be here. So, you know, one of my favorite things to do in my office, believe it or not, is conduct a sexual health consultation. These are very in depth, they're very personal. But I really feel that they are so incredibly rewarding because I can really help people with very concrete bits of advice regarding sexual health. So, I'm hoping we're going to touch on a lot of those topics today.
Defining Desire, Libido, Sex Drive and Orgasm
Sarah: Yeah, for sure. Yeah. And just a bit of information about the format. We're going to start with the concepts that we mentioned, changes in desire and orgasm, and then go into the causes and the treatments. And then the remainder of the session will be reserved for Q&A. If you have questions, you can add them into the comment section.
I think we're ready to get started. So, we know that many women experience changes in sexual satisfaction, as they age and in different parts of their lives. Right. And so today, we're going to talk mostly about changes in desire and orgasm that occur during the menopause transition. And so, I think we should start by defining those two areas, desire and orgasm and discuss how they're different.
Dr. Dweck: Desire, in colloquial terms, basically just means your interest in sexual activity, wanting to want sexual activity. So, that's a colloquial way of defining desire. I think it is incredibly important to understand that it is natural for desire to ebb and flow throughout the lifecycle. Not everybody is going to have a 110% desire every day of their lives.
There are things that will certainly get in the way and we're going to talk about that.
Menopause is one of those times where desire may change a little bit, as far as other definitions as they relate to desire. There is something that's been spoken about quite a bit called hypoactive, sexual desire disorder or HSDD and this is really more of a core, chronic lack of desire that causes distress for somebody. That's not really what I see people in my office for regularly because that affects maybe one in 10 women. But I thought it was important to distinguish that.
Then there's also incongruent desire where one partner, if there's a partner relationship, is interested more so than another, and that we can dive into a little bit as well.
Sarah: Okay. And also, the terms like libido, sex drive desire, they're all kind of the same thing.
Dr. Dweck: Yeah. I think that we normally talk about libido, or sexual drive or desire as interchangeable terms. These are a little different than arousal, which is really more the physical results of desire, like lubrication, but for the most part, desire, libido, sexual drive are kind of synonymous in terms of tonight's discussion.
Sarah: Awesome. That makes sense. And then moving on to orgasm. How would you define it from a medical standpoint?
Dr. Dweck: What I usually say is that if you're having one, you don't need a definition, you will know about it. But it's essentially the climax, the culmination of sexual activity, with a release. And with that comes incredible satisfaction, pleasure, and also the release of, you know, many neurotransmitters and hormones.
Sarah: That makes sense. So, desire is more libido, how are you feeling about sexual experiences and things like that, and orgasm is more of a physical sensation that comes along with sexual experiences, and as a result of sex.
Dr. Dweck: Exactly, and there are physical things that of course, come along with orgasms such as, you know, encouragement of the blood supply to the genital area, the contractions of the uterus, which can occur. But again, if you're experiencing that, you'll know about it.
How Sexual Desire Changes During Menopause
Sarah Okay, perfect. I think it's good to define those two areas up top. Let's dive a bit deeper into desire because I know that those changes are something that a lot of women experienced during the menopause transition.
Can you kind of give a background of how desire changes during menopause and perimenopause? And maybe have some examples of how you see that in your practice?
Dr. Dweck: For sure. So, look, as I said before, desire can ebb and flow throughout the lifecycle. Menopause is a specific time where this can happen because of the decline in hormones, specifically, estrogen, progesterone, and also testosterone, a male hormone that we all make, but we make less with age and over time. So, the ratios of these hormones and the actual amounts of these hormones can influence desire. It's also really important to understand that there's so much that goes into desire, whether it's psychological, emotional, physical, medical, blood flow issues, medications, you name it, they can influence desire. And many of these things will come up with age, which also includes menopause. So, we can talk about each one of those individually.
What Influences Changes in Sexual Desire During Menopause?
Sarah: That’s a good transition. My next question is more about the symptoms. And it sounds like there can be three different areas that cause changes in desire, maybe it's your relationship, some emotional influences, and maybe some different medical influences, like different health conditions, and also medications.
Dr. Dweck: For sure those areas. So, these are things that I really delve into in a thorough history with my patients, when they come in with concerns about a desire that's not satisfying for them.
First and foremost, we talk about relationship. If somebody is in a partner relationship, and they resent their partner, they're angry at their partner, they perhaps are thinking that they don't like the physical appearance of their partner, these things that are going to interfere with their desire. Many, many times I rely on my mental health colleagues to help me navigate couples counseling or to provide individual counseling to help with some of those feelings that might be interfering with desire.
Oftentimes, there's just stress going on in life, whether it's financial stress, you know, stress with kids, stress with jobs, you're thinking about the laundry, you're thinking about shopping, whatever it is, and that can get in the way of your desire.
Sometimes there are medical issues. After all, if you're in physical pain, like from a surgery you've had or arthritis or an autoimmune issue or something along that line, that's going to interfere with your sexual drive.
Sexual Desire and the Effects of Antidepressants
We also think about things like depression and anxiety and other mental health issues that can absolutely interfere with desire. In fact, low sexual drive may be a symptom of these issues, and those need to be addressed. And sometimes the very medications that we use to treat this can be at the core of why desire is low.
For example. Certainly, antidepressants can really cause a lower desire. So, these are things that we tease out during a big, long history taking process that I do in the office. One thing that often brings a lot of emotion is what we call sexual self-esteem. This just means how do you feel about your self-image, your body image, and many women, as they are approaching or traversing menopause, are maybe not as happy with their muscle tone, or their weight, or their exercise regimen as they might have been in past. And this can translate into a lower desire. So, we work on all of these aspects, even all at once, in an effort to help enhance desire.
Addressing Multiple Causes of Decreased Sexual Desire
Sarah: I was going to say it sounds like there's so many different factors at play. So, I'm curious, if someone comes into your office and is saying, I have a problem with desire, you know, there's a lot of different buckets. I'm just curious, where do you start? And how would you help treat them and address all those different issues knowing there's various areas that are causing this?
Dr. Dweck: So, obviously, I assess the relationship status, I assess their social status, are they very stressed out working? Do they smoke, do they drink a lot of alcohol? We talk about medical issues. I usually will run a big blood panel to check for things like thyroid disorder and other hormone imbalances and perhaps a blood count to see if somebody's anemic or review their chemistry panel to see if there are alterations in liver function or kidney function. I often check hormone levels as well to kind of see where people are in the menopause.
All of these things are put together in an effort to get to the bottom of what might be causing low desire.
Sarah: I was going to also mention that sexual pain can be a big factor as it relates to desire.
Dr. Dweck: Yeah. Because if someone is anticipating pain during intimacy, what would be the natural reaction, but to avoid intimacy, because who wants to endure pain that they don't have to? We spoke about this a lot during our last Instagram Live. But managing vaginal dryness and discomfort during sexual intimacy is very, very important and runs hand in hand with desire.
Sarah: Okay, that's really important. I'm glad you brought that up. And the question I was going to ask is, do you see a cause that’s more common in your practice? Like you were saying, you could check for hormone levels or different types of medical conditions? Or if it's more relationship issues, I'm wondering if there's an area that's more common?
Dr. Dweck: You know, I think I see so much of all of the above. But vaginal dryness and discomfort during sex is a really huge problem for the menopause population. So, that's something that we typically address first.
Alongside other issues, I do pick up quite a few thyroid abnormalities, that's the gland in your neck that regulates metabolism, and that can really alter general health, but specifically impacts desire and sexual health and satisfaction. And look, you know, we're seeing more and more people dealing with diagnoses like breast cancer or other issues that might require surgical intervention. And so, we want to address those medical problems as well.
One final thing that's so important is blood flow. So, blood flow to the genital tissue gets altered by other medical issues like diabetes, like cardiovascular disease. So, these things need to be managed in order to enhance blood flow, and keep the tissue in the genital area, lush, comfortable and elastic.
Treatments for Changes in Sexual Desire During Menopause
Sarah: A lot of different things to consider there. But it’s really amazing that doctors have the ability to kind of consider all these different issues and have a fully comprehensive approach. And then that leads me into my next question which is about how you can treat these symptoms of changes in desire. So, maybe you want to talk through some different treatment options that you have?
Dr. Dweck: For sure. So again, a lot of this depends on somebody's individual situation. Obviously, we address relationship issues. And I don't mean to suggest that relationships may be bad to cause low desire, because oftentimes, somebody can be in an incredibly happy partnered relationship, but they've been in that relationship for a very long time, and sexual boredom may set in. So, what do we do here, we need to spice it up a little bit. I often recommend like a very specific penned in the calendar date night, so that you put everything else aside, doctor's orders, and engage in date night and do something fun – and if it ends in intimacy, great, but that can spice things up a little bit.
We often recommend something called bibliotherapy, which is just kind of a fancy way of saying, start reading romance, start reading erotica. Think about watching suggestive videos, you know, whatever somebody is comfortable with, to help get sexual thoughts on the brain because eventually, once those thoughts are around, they will then come about spontaneously, and help to increase desire.
Sarah: So, it's kind of like training?
Dr. Dweck: Yeah, exactly. And then lastly, mix it up or spice it up a little bit, you know, you have a happy relationship, let's say, but maybe you're so used to engaging in the same sexual repertoire all the time – go to another room to have intimacy, change up the time a day, maybe roleplay a little bit. And this can really help to spice things up in a happy, but maybe somewhat complacent relationship and then can enhance desire. That's one place we start.
Sarah: Okay. Can I ask you a quick question? We're talking about relationships… what if someone isn’t in a relationship, but still does want to do similar types of things as you’re suggesting? Any advice for them?
Dr. Dweck: Absolutely. It's all about blood flow in this case, and also the sexual thoughts. I often recommend vibrator use to help enhance blood flow, just like any massage would do. That's what a vibrator can do to help enhance blood flow to the genitals. And for those who feel shy about this type of recommendation, I will often write a prescription “doctor's orders use your vibrator once a week or to dust off your vibrator once a week” in an effort to help regenerate the blood flow and also those good feelings of sexual response. Unpartnered sex can be very enjoyable, either while waiting to find a partner that you're interested in or just because!
Sarah: Yeah, that's helpful. So, I think you were maybe going to start talking about other types of treatment options, maybe different types of medicines or other non-hormonal treatments.
Dr. Dweck: Obviously, [be sure you’re] treating any medical diseases we’ve spoken about and examine your medications to see if something may be altering your desire.
Oftentimes, I will recommend a supplement to help enhance blood flow, and also something to help with vaginal moisture, whether that's a vaginal hormone, like minimally absorbed vaginal estrogen, or whether that's an amazing hyaluronic acid, moisturizer like Revaree®, from Bonafide. Just something to help facilitate discomfort, so that we're not practicing avoidant behavior. As far as blood flow, I often recommend a supplement like Ristela®, also from Bonafide.
The way Ristela works is that it helps to enhance blood flow by dilating the blood vessels during the sexual response. And this is an herbal supplement that works by increasing this amazing ingredient in our bodies, called nitric oxide, to help dilate the blood vessels and enhance blood flow. So, that's an excellent way to start.
Lastly, although it is not FDA approved for women, it is frequently recommended; testosterone – sometimes we will use a hormone called testosterone. Again, not for everybody, but for those who are interested, it’s available topically, as a compounded medication, and it is a prescription in order to enhance sexual drive a little bit.
Sarah: Okay, yeah, that makes sense. And is there any sort of thing that someone can do physically, like any types of exercises that maybe could help with desire in any way?
Dr. Dweck: You know, some people just practice regular exercise so that they feel like their sexual self-esteem is optimized. Chemicals, exercises, and pelvic floor exercises could be very helpful for those dealing either with a lax vagina, who wants to just firm up the muscles a little, or for those dealing with sexual pain, because their muscles are too tight. And oftentimes, I'll recommend seeing a pelvic floor physical therapist for those types of exercises.
Talking to a Healthcare Provider About Changes in Sexual Desire
Sarah: Okay, that makes sense. All right – I think that was great. We covered a lot; how does desire change, the symptoms and the causes and how to treat it. And so, the last question I have for you on this topic is how to talk to your doctor about changes in desire. I think that can be a sensitive topic and this is a great forum for us to talk about that.
Could you give some advice to everyone watching here?
Dr. Dweck: Yeah, well, luckily, this is becoming a little bit more of a more comfortable conversation for people to have and forums like this are the ideal circumstance for that.
I think direct conversation is best.
There will be providers who are very comfortable discussing sexual health topics and others who are not as comfortable, but who should be able to refer you to somebody who feels comfortable with not only discussing, but treating. I often recommend resources like NAMS, the North American Menopause Society; they have a list of certified medical menopause providers who are very well versed in this topic.
On more of the mental health side, an organization called AASECT, which are mental health providers that specialize in sexual health, may be a good resource. And this is particularly helpful for those who are dealing with, you know, maybe a past history of trauma or abuse or relationship issues or trust issues, or marital discord. And I think that would be a very good resource as well.
Sarah: That's great to hear that there's so many different resources out there.
Dr. Dweck: I did want to bring up one last thing again, this diagnosis called HSDD: hypoactive sexual desire disorder. This is very different there than just low desire, okay? This is a situation that occurs when someone has absolutely no sexual thoughts on their own, or with a partner. And it's distressing to them. Some people will come in my office tell me they really don't have much of a desire, but it doesn't bother them at all. They go about their business, it's not distressing. But this particular diagnosis [HSDD] is very distressing to people when it occurs, and there actually are pharmacologic remedies for this that have been approved by the FDA. One is called Flibanserin [generic] and one is called, Vyleesi, a brand name. And although these are not commonly prescribed, they are options for people dealing with this condition.
Defining Orgasm and Addressing Changes in Orgasm During Menopause
Sarah: That's super helpful to know how to get the best type of treatments that are out there. Okay, that's really helpful. I feel like we covered desire pretty well; so, I think it would be a good time to kind of go into orgasm more. I think it would be helpful to go through the same types of questions. If you could start by defining how orgasm changes during menopause, perimenopause, that'd be a nice start.
Dr. Dweck: What most people complain about in my office is that they may still be able to achieve orgasm, but it is much more difficult to achieve. And it also might be a lot weaker than what they expect, based on their past. Part of this is clearly hormonal, there's no question about it, the tissue becomes more delicate, the clitoris may not be quite as sensitive. And this can be distressing. And there are some ways to deal with that. A lot of this is also, dependent on the biggest sex organ, which is, you know, right between our ears, our brains.
So, somebody may be distracted, because of kids at home, a lack of privacy, or they fear that somebody's going to maybe hear them, which a lot of women do worry about since they have children at home. If they don't feel 100%, you know, comfortable with their weight, let's just say or their [muscle] tone, they may get in their own heads and not really be able to focus enough to achieve orgasm.
Mindfulness can be quite helpful for this type of situation. As far as weakened orgasm, you know, we usually practice mindfulness, sometimes we talk about direct clitoral stimulation, rather than just worrying about penetration. And also using a supplement that may enhance blood flow to the genitals like Ristela or adding a vibrator or a toy to the to the repertoire.
A lack of orgasm completely, might have some medical route to it. Sometimes we do look for organic issues for this, whether it's nerve compression or something from post-surgery. But many, many times it also is a super personal thing, that it's something emotional – interesting trust issues going on or relationship issues or just plain old distraction.
Sarah: Yeah, that's interesting to hear; that mind body connection. So, does that mean that the kind of the types of treatment options are a little bit similar to desire for orgasm? Because it's also partly mental or how do the treatments options differ?
Dr. Dweck: Well, in general, they are all associated with each other. Once again, providing potentially a supplement, or some hormone support, particularly vaginal estrogen or even testosterone, might be helpful. Blood flow is so important when it comes to orgasm. Vibrator use may be helpful, but one thing that I think a lot of people misunderstand is that it really is about direct clitoral stimulation when it comes to achieving orgasm. Partners may need to have direct communication about exactly what spot feels right, rather than leaving it up to a guessing game. Okay? And so that's something that I often recommend to my patients, to let your partner know where it feels good and maybe this is where it doesn't feel so good anymore. Also think about minimizing dryness and eliminating as much pain as possible because really achieving orgasm is going to be difficult if there's the anticipation of pain.
Sarah: You brought up talking to your partner about this. And I was curious if patients come to you and ask “how can I talk to my partner?” For instance, if I'm having diminished orgasm, or something like that? Do you have any advice in that area?
Dr. Dweck: Again, I usually suggest direct conversation. Unfortunately, people can't necessarily read our minds, particularly our partners. So, it just might be important to say, “I'm really enjoying, you know, caressing or kissing. But when it comes to achieving orgasm, I need you to touch me here, or I need you to do it like this.” So, it might just have to be that direct. Often exploring on your own could be the way that you can relay this to a partner too.
Questions About Changes in Sexual Desire and Orgasm During Menopause
Sarah: Makes sense. Perfect. All right, I think we covered everything that we wanted to go through. So now we want to open up the Q&A. We have some questions here so I can start with the first one. And that is, is there anything else I can do to strengthen my vaginal tissue that keeps ripping and it's causing pain during and after sex?
Dr. Dweck: Yeah, this is a pretty common complaint that I see in office. And again, less estrogen during menopause means less natural blood flow to the vagina and the genital tissues and less elasticity. The tissues become really prone to injury and intercourse itself may be what's causing these fissures and this discomfort.
I usually start off with an aggressive moisturizer and lubricant protocol – what does that mean? Typically, I'll start off with something conservative, hyaluronic acid, you know, moisturizers like Revaree would be ideal to be used every two to three nights, as a way to really provide extra moisture and help the tissue to become more elastic, less delicate, less prone to injury, okay. I also recommend a lubricant to be used during intimacy, especially if penetration is involved, because that will diminish some of the friction. And a silicone lubricant might be ideal, because it's long lasting, it doesn't necessarily change the pH or the milieu of the vagina, and again, it's longer lasting, and a little bit goes a long way.
Okay, that's how I would start out. From time to time, if that's not enough, then adding or replacing with a minimally absorbed vaginal estrogen, if you are candidate for that, can be very helpful.
Some people benefit from using a dial dilator program. What are dilators? Dilators are small little cylinders that usually come in a set, and they gradually get wider and wider. And we encourage people with vaginas to do exercises with these dilators to not only mechanically stretch the opening, the length and the width of the vagina on a gradual basis, but it also teaches people and trains the brain not to anticipate pain and tighten up those muscles.
So, a combination of aggressive moisturizers and lubricants, perhaps topical estrogen if indicated, and dilators can really help with this type of issue.
Sarah: Okay, yeah, that's great. It's great that there's a bunch of different areas, and there's always more we can do, but that's a really great way to get started. Okay, awesome. That's very helpful. So, the second question is, is there a difference between clitoral orgasm and vaginal or orgasm? This person is premenopausal but is curious if you can kind of like lose one or the other if there's difference between the two?
Dr. Dweck: Well, this is going to be the age-old question that I'm not sure ever gets fully answered. Because there are certainly schools of thought that think all orgasms emanate from essentially the same place, the clitoris, and whatever you feel vaginally, if you experience a vaginal orgasm, it really is just an extension of the clitoris. So, I would venture to guess that these are just different types of orgasms that occurred based on different stimulation. And I don't think that one would lose one or gain one over the other, it really probably just has to do with the activity.
And remember, the clitoris is not just the little, teeny, dime sized organ that's external; it actually extends quite a bit, almost like in the shape of a wishbone, so that crura or the legs of the clitoris, extend down the labia, and a lot of the blood supply extends into the anterior wall of the vagina, which is probably where vaginal orgasms really emanate from. So, it probably is all related to the same mechanism.
Sarah: That's, that's really interesting. Okay, so the next question is if someone is in perimenopause, and sex drive seems to have increased. Is that possible?
Dr. Dweck: Yes. So, you know, during perimenopause, your hormone levels, including estrogen, progesterone, and testosterone, are all fluctuating. The ratio of testosterone and estrogen may really change when these things become volatile. And so, if there's testosterone dominance, you may really feel an enhanced libido. I hear this from patients. In fact, some of my patients have come in almost embarrassed to say, I almost feel like I'm too sexual at this time, what's going on? And they say it was a little smile. But unless it's distressing, this is not a problem. Sometimes I will check hormone levels including thyroid testing, because overactive thyroid can cause hypersexuality as well as some other hormonal imbalances. For the most part, some perimenopausal women will experience an enhanced sex drive during that time. Okay. So, enjoy it!
Sarah: Good to know. That's helpful. Okay, next question is about hot flashes and other menopausal symptoms and if they can affect your sex drive?
Dr. Dweck Sure, because if you think about it, number one, hot flashes are physically uncomfortable, and they can be debilitating, especially if they're recurrent all day, every day. Hot flashes at night or night sweats can also interrupt sleep, really alter the quality of sleep and make people tired and irritable. I can't think of anything that would be more distressing to sex drive than being exhausted, physically uncomfortable, sweaty, and just not feeling yourself. So again, treating hot flashes, managing night sweats is going to be helpful for general sexual activity and satisfaction.
Sarah: Another question came in about if someone's orgasms can feel muted in a way, she was asking. Are there any exercises she can do to help with this? I think we touched on that a little bit…
Dr Dweck: I would encourage vibrator use if that's a comfortable thing, because again, that's going to enhance blood flow and make it more sensitive. Remember to address dryness, or even if you don't necessarily feel dry, consider using a moisturizer, whether it's a hyaluronic acid-based moisturizer, or even vaginal estrogen, if you're a candidate for that, to help with the sensitivity of tissues, and also to help make the tissue more lush and more, you know, inviting, if you will, and less prone to injury. So, that will help. Okay, if orgasm has just literally gone to a dead halt in a quick period of time, that needs to be checked out just to make sure there's nothing going on otherwise.
Sarah: Okay. That's good to know. Another question we had coming in said, I never even think about sex anymore. Is there something wrong with me? I feel like we've obviously touched on that.
Dr Dweck: It is a good question. There's a distinction between just having a transient, lower desire than what is typical for you, and then really having not one sexual thought ever. Not even on your own. Not even if, I don't know, your version of Brad Pitt walks through the room, and being distressed by it. So, if this is a distressing situation, and it's been going on for a period of time, and it's not situational, like related to grief; and you're not going through a medical issue or something of that nature. Please then get it checked out. Because there could be something medical going on, that's just beyond the menopausal hormone changes.
And, you know, Kegel exercises, whether it's on your own just while you're driving or doing dishes or whatnot, or with an exerciser, or with a dilator that also functions as a vibrator – these things can be good exercises to help enhance orgasmic response, and maybe even enhance desire. So, something to keep in mind.
Sarah: Then another question we had is about the time it takes to get aroused. So, someone said that it takes a really long time to feel aroused. Do you have any advice on that specifically?
Dr Dweck: It may take longer with age; it may take longer with menopause. And this is in part due to blood flow and in part due to hormonal changes, and also based on all of the issues that we spoke about that might contribute to diminishing desire.
Arousal specifically is the physical response to a sexual drive, the lubrication that occurs in the vagina. So, if you're not getting enough lubrication, it's either because you need to use a moisturizer or vaginal estrogen, or because you need to get your mind more focused on desire and arousal in general. And that can sometimes come with that bibliotherapy exercise that we talked about earlier. And can be helped by enhancing blood flow in whichever way you choose whether it's with a supplement, or whether it's with a vibrator, or manual stimulation or all of the above.
Sarah: I feel like a lot of your answers to these questions are great, because it sounds like there's a lot of different ways you can approach this [issue]. And if maybe something isn't working for someone, and they don't feel comfortable with that, there's another option. So, I think that's really encouraging to hear.
Dr Dweck: There's always hope.
Sarah: Yeah, exactly. All right. Let me see if there's any more questions in the comment section that we can get answered – or are there any questions you commonly get from patients?
Dr Dweck: I'm so glad you brought up what I see in my office, because I would say that the most common situations that are presented to me are:
- Number one, don't give up on having sexual pain. “What can I do about that?”
- Number two, “why I never think about sex or if my orgasm is really muted. How can I enhance that?”
- Number three, “my orgasm just isn't the same”.
And these are the three things that I really am managing on a day-to-day, regular basis. So, these questions make me realize and should make the audience recognize that these are common issues. And you're not alone. And absolutely bring them up to your practitioner. I'm sure many people are more comfortable discussing with their girlfriends or, whatnot. But, you know, there definitely are healthcare providers who are well versed in this field.
Sarah: And I feel like it's becoming like more of an open conversation, meaning you can go to your doctors, your friends, and there's a lot of online resources and things like that. So, for sure. Great to hear.
Another question we have is, how can I talk to my partner about changes in my sexual function during menopause? And I think we spoke a little bit about it, but maybe just to reiterate.
Dr. Dweck: You know, I think it's very important to recognize that for heterosexual partners, men don't necessarily understand exactly what women may be going through during menopause. And one thing I really notice, especially when I see couples together, is that, you know, male partners don't want to hurt their female partners.
Yeah, so managing pain is a big deal. And we really need to let our partners know if there's pain during a particular activity so that it can be addressed. Number two, it's important to say to a partner directly, “I like this activity. I don't like this activity”.
So, something comes to mind that I've seen in my practice before patient comes in. She's really having an issue with desire, because she no longer really enjoys having her breasts caressed in any way, which used to be part of maybe sexual play in the past, but ever since she had surgery for breast cancer, this is no longer enjoyable for her, and her partner doesn't necessarily know this. And so, she needs to tell her partner, “I need to let you know that this is no longer an enjoyable activity for me, maybe because of surgery or you know, the image that I have, or it's painful,” and let them in on that because they can't necessarily read minds. Or let a partner know, that “ever since I had a hysterectomy, intercourse is a little bit uncomfortable. I really need a lot more stimulation before we attempt intercourse.” This is something that a partner needs to know. They may not be aware of that. So, this is what I mean by direct conversation.
Sarah: Yeah. And sure, it's probably better to kind of have it on an ongoing basis. And probably before you're having sexual intercourse. It's kind of just a part of the conversation. Yeah. And, you know, can just be a normal conversation.
Dr Dweck: And I will also say that the patient doesn't bring this up to me, I will often ask because, you know, maybe they don't know how to find the words to ask me these specific questions.
Sarah: Yeah, that makes sense. It's very helpful. So, we did have another question come in about a little bit of confusion around like the pelvic floor. So, is there a way to tell if it's too tight or too loose? Do you have any advice in that area?
Dr Dweck: Yes. So, some people will complain about what we call “vaginal laxity”. This is just kind of a fancy term of saying the vagina has become much more spacious, looser, maybe due to genetic factors, maybe due to having had babies vaginally that were really big or instrumented as far as deliveries like forceps or vacuum or something of that nature. And so, some people do complain of, you know, a “gaping vagina”, if you will.
Pelvic floor physical therapy and exercises can be helpful to help to tighten muscles again, so that there's a little bit less of a lax feeling. This is in contrast to what we call a hypertonic pelvic floor, where the muscles of the pelvic floor become almost too tight, because they're constantly on guard trying to protect anything from getting in there, because [there’s the thought that] it might be painful. And pelvic floor physical therapy can help with this as well, by helping to try to relax these muscles to allow for less discomfort. Okay, so I hope that makes sense. So, they're similar etiology, similar issues in the vagina with the musculature, but different causes and different management.
Sarah: That's also interesting about postpartum and how I'm sure a lot of women in that area have a lot of sexual arousal and desire issues because of the physical changes, but also probably the hormonal changes.
Dr Dweck: Look, you know, after childbirth, immediately, of course, especially if somebody is lactating, they're going to have changes in the vagina due to low estrogen. And so, they will have similar changes as somebody in menopause where the tissues are very delicate. Using a hyaluronic acid insert for moisture used regularly during this time can be extremely helpful.
After lactation is completed, you know, and ovulation returns, estrogen should replenish in a younger person. And natural changes should revert to pretty much normal when it comes to lubrication and all.
Sarah: That's good to know.
All right, well, I think we can wrap up here. Thank you, everyone, for the great questions and thank you, Dr. Dweck, for being here. We appreciate everyone's time and we just wanted to remind everyone that there will be a recording of this session available in the upcoming weeks on our blog, as well as on Facebook and Instagram – so you can check that out and review all the content then!
If you had any questions that we weren't able to get to, please reach out to us via a direct message [or email firstname.lastname@example.org] and we're happy to answer your questions and get back to you. This forum was designed for you – we want you to feel like we're here for you to answer your questions – and we're really excited to be able to do that. So, thank you again!
Dr. Dweck: There's never been a better time to talk about this subject. Thank you!