The research reflects what many women report—that as they transition from menopause into postmenopause, sex becomes painful. There is strong evidence from observational studies that “menopause causes vaginal dryness,” which in turn often leads to dyspareunia (pain during intercourse), according to the National Institutes of Health (NIH).1 And a recent, large cohort study of British women examined sexual function throughout menopause and found that vaginal dryness was “strongly associated with both decline in sex life and difficulties with intercourse,” including dyspareunia.2
Although prevalence is difficult to determine, vaginal dryness has been estimated to occur in 4% to 22% of premenopausal women, 7% to 39% of perimenopausal women, and 17% to 30% of postmenopausal women.1 Weijmar Schultz and colleagues, reporting on a consultation among members of 17 international committees, found that the prevalence of dyspareunia in women ranges from 3% to 43%, with estimates varying by culture, setting, and whether the provider raised the issue.3 Commenting specifically on the importance of the last factor, they state that “in order to detect sexual problems and sexual dysfunctions, explicit questions will have to be asked.”
(This article uses the terms perimenopause, menopausal transition, and postmenopause to describe distinct but overlapping stages of reproductive aging. These terms were used by the NIH in its 2005 State-of-the-Science Conference Statement: Management of Menopause-Related Symptoms, based on nomenclature proposed by the Stages of Reproductive Aging Workshop in 2001. For brief definitions, see Female Reproductive Aging, below.)
Vaginal dryness is one of the most common symptoms of vaginal atrophy, the thinning of the vaginal epithelium that occurs as estrogen levels drop. (If accompanied by inflammation, the condition is called atrophic vaginitis; if atrophy of the bladder and urethra also occurs, it's called urogenital atrophy). In addition to dryness, symptoms of vaginal atrophy include vaginal itching, burning, pressure, or a combination of these.4 Findings on examination may include a loss of elasticity and shortening of the vaginal barrel, diminished vaginal secretions, loss of vaginal rugae, and rising vaginal alkalinity (a pH level of greater than 4.5).4, 5
Besides estrogen (specifically estradiol) deficiency, suggested causes of vaginal dryness include sensitivity to products such as vaginal sprays and wipes; drugs such as antihistamines, antidepressants, and nicotine; tight-fitting clothing; and cessation of sexual intercourse.4
Dyspareunia remains inadequately understood. Psychological as well as physical factors can play a role. Weijmar Schultz and colleagues recommend defining it as “persistent or recurring pain with attempted or complete vaginal entry and/or penile vaginal intercourse,” a definition that does not presume a particular sexual preference.3
Sexual arousal, which involves vaginal engorgement and lubrication, is sometimes decreased in patients with dyspareunia.6 Decreased sexual desire (libido) secondary to dyspareunia and impaired arousal may be reported,6, 7 and the frequency of sexual activity may decline.8 Studies have shown premenopausal women (who presumably have normal estrogen levels) have enough lubrication that even in the absence of arousal, vaginal penetration can occur without pain.9 But for women in peri- or postmenopause with vaginal atrophy, dyspareunia can lead to a loss of interest in sex and affect the quality of their lives.10 However, it's also been suggested that in postmenopausal women who experience this dyspareunia may result from a preexisting arousal disorder that was not identifiable until “unmasked” by the effects of estrogen depletion.9
There is some evidence that, compared with women who go through the menopausal transition naturally, women who undergo surgical menopause after bilateral oophorectomy may experience more adverse effects; this is assumed to be the result of the abrupt decline in circulating estrogen and other hormones.11 Women diagnosed with breast cancer are often treated with drugs such as tamoxifen (Nolvadex) and aromatase inhibitors (such as anastrozole [Arimidex]), which induce estrogen deficiency; menopausal symptoms are common. One study found that women with breast cancer who took aromatase inhibitors had “more atrophic symptoms,” including dryness and dyspareunia, than did women who took tamoxifen.12 Another study suggested that younger breast cancer survivors tend to have significantly worse dyspareunia than older survivors, regardless of how the cancer was treated.13
Chronic dyspareunia may have several consequences. Commonly, the association of pain with sex leads to avoidance of sexual stimuli; even stimuli that aren't avoided “are unlikely to lead to arousal” because the anticipated outcome is pain, not pleasure.14 This affects not only the woman with dyspareunia but also her partner; intimacy may be decreased or lost as “confusion, resentment, anger, and sadness replace feelings of closeness.”14 A woman with dyspareunia, for example, may be afraid that her partner will initiate sex, and may feel “used” and angry if she engages in sex despite the pain; her partner may be afraid to initiate sex for fear of causing pain and may feel rejected.
ASSESSMENT AND TREATMENT
Addressing vaginal atrophy and dyspareunia involves both physiologic and psychosocial factors. Providers should routinely assess peri- and postmenopausal women for signs and symptoms of vaginal atrophy and dyspareunia. These are particularly sensitive topics for many women. In my experience, most women find it much easier to talk about other symptoms of menopause, such as hot flashes, than pain during intercourse. Providers should introduce these topics even if patients do not. Suggestions for doing so using the PLISSIT and BETTER models are above and on page 36, respectively.
The pelvic examination should include visual assessment of the vaginal epithelium. Typical changes seen during and after the menopausal transition include loss of rugae and a pale, dry appearance; submucosal petechial hemorrhages may also be seen.10 The labia majora and minora should also be assessed, as they frequently shrink during this time. Not all women with vaginal atrophy are symptomatic. Laboratory indicators of vaginal atrophy—which include a vaginal pH level of greater than 5 and a predominance of basal cells in the vaginal wall—“are not particularly useful clinically.”10
Nonpharmacologic treatment. Because smoking can accelerate the loss of circulating estrogen,15 smoking cessation should be emphasized for these patients. It's known that sexual stimulation promotes vaginal blood flow and increases lubrication; thus, for women with dyspareunia, masturbation and nonpenetrative sexual activity may have beneficial effects on vaginal tissues.9
Pharmacologic treatment may include the use of vaginal moisturizers and lubricants, systemic or local estrogen therapy, or both.
Vaginal moisturizers have been shown to be as effective as local hormone treatment10 and may be preferred by women who don't want to use hormones. Vaginal moisturizers increase the amount of water in the vaginal tissues. One product (Replens) contains a polycarbophil capable of retaining up to 60 times its weight in water4; when the gel is applied to the vaginal mucosa, the water it carries diffuses into vaginal tissues over a period of 48 to 72 hours, according to the manufacturer. As the epithelial cells regain moisture, elasticity is restored and dry cells that have built up are shed. According to one review, this product can be reapplied every two to three days and reapplication before intercourse isn't necessary.4
Vaginal lubricants are also useful for relieving dryness during intercourse, but they are shorter-acting than moisturizers. Commonly used lubricants include water-based products (such as K-Y Jelly and Astroglide), silicone-based products (such as ID Millennium), vegetable oils, and glycerin. Some moisturizers and lubricants can compromise the integrity of latex, making condoms less effective, so women should check with their provider.4
Hormone replacement therapy. Systemic hormone replacement therapy (HRT) has been found to be effective in relieving vaginal atrophy and other menopause-related symptoms. However, given concerns raised by the Women's Health Initiative studies—which include the findings that systemic HRT with estrogen alone was associated with increased risk of cardiovascular disease, while systemic HRT with estrogen and progestin was associated with increased risk of cardiovascular disease and breast cancer—it is generally accepted that local HRT is the treatment of choice. Local HRT offers relief without the associated risks.
Estrogen can be delivered locally in a cream, in a vaginal tablet, or with a vaginal ring. Estrogen cream (which may contain either estradiol or conjugated equine estrogen) is effective in reducing vaginal dryness, but because it is a form of unopposed estrogen therapy, progesterone supplementation is required to reduce the risk of endometrial hyperplasia.5 (An elevated estrogen level is associated with an increased risk of endometrial hyperplasia; of the three local delivery methods, creams containing conjugated equine estrogen appear to contain a higher relative dosage and thus have a higher potential for systemic absorption.5, 16) Some women also report that estrogen cream is messy, and anecdotal evidence suggests that compliance is not high. A vaginal tablet containing estradiol (Vagifem) has been shown to be effective within two weeks of initiating daily treatment16 and appears not to cause endometrial proliferation, so concomitant progesterone administration is unnecessary.10 The estradiol-containing vaginal ring (Estring) has also been shown to be effective, does not cause endometrial proliferation, and is preferred by women to estrogen creams.10, 16 The ring is inserted and normally remains in place for three months; women who find the ring uncomfortable during the day may achieve symptom relief by inserting it only at night.5 It should be noted that regardless of delivery method, “data are limited about the use of local estrogen therapy for longer than six months.”16
Although local estrogen therapy may relieve the symptoms of vaginal atrophy and dyspareunia, women who feel their sexual satisfaction has diminished with menopause may benefit from counseling with a sex therapist. If decreased sexual arousal continues even after vaginal atrophy and dyspareunia have been treated effectively, different methods of sexual stimulation (such as oral or manual techniques) may be helpful, although changing lifelong practices can be a challenge.
Female Reproductive Aging
Reproductive stage: The time from menarche (first menstrual period) to the beginning of perimenopause.
Perimenopause: The time when estrogen levels begin to drop, follicle-stimulating hormone levels begin to rise, and menstrual cycles become variable. Early perimenopause is marked by cycle lengths that vary by seven or more days from normal; late perimenopause is marked by two or more skipped cycles and an interval of amenorrhea of 60 days or more. Perimenopause is considered to overlap with the first 12 months of postmenopause.
Menopausal transition: The time from the beginning of perimenopause through the final menstrual period.
Postmenopause: The time after the final menstrual cycle. (Many physicians consider postmenopause to begin at one year after the final menstrual cycle.)
Soules MR, et al. Fertil Steril 2001;76(5):874–8; National Institutes of Health State-of-the-Science Conference statement: management of menopause-related symptoms. Ann Intern Med 2005;142(12 Pt 1):1003–13.
Using the PLISSIT Model
All nurses should be able to function at this level—for example, by making a general statement that normalizes the topic.
- Example: “Many women find that as they go through menopause, sex is painful. Have you noticed any changes that you would like to talk about?”
Most nurses should be able to give this kind of information.
- Example: “Sex should not hurt. For the pain you've been having, vaginal moisturizers may be helpful.”
Requires a higher level of expertise on the part of the nurse, who must be able to provide anticipatory guidance on possible sexual consequences of medications and other treatments.
- Example: “Women with breast cancer taking tamoxifen often report extreme vaginal dryness and pain with attempted intercourse. I suggest that you talk with your oncologist about using local estrogen, which may help ease the pain and burning.”
Usually requires a referral to a sex therapist or specially trained counselor.
- Example: “Changes in sexual functioning sometimes create challenges in a relationship. It sounds like you and your partner are having some difficulties communicating. I'd like to refer you to a counselor who can help you learn constructive ways of talking with each other.”
Annon JS. The behavioral treatment of sexual problems. 1st ed. Honolulu, HI: Enabling Systems; 1974.
Using the BETTER Model
Bringing up the topic.
- Example: “I'm going to ask you some questions about changes you may have noticed during menopause. These include some questions about sexual functioning, an area many women have concerns about.”
Explaining that sex is a vital part of life helps the patient to feel less embarrassed or alone.
- Example: “Some women find it difficult to talk about sexual functioning with their health care providers. I talk about this with many women in my practice and I hope that you will find it easy to talk with me.”
Telling the patient that resources will be found to address their concerns, even if the nurse doesn't have an immediate solution.
- Example: “I know several providers who are very experienced in dealing with symptoms such as yours. I can give you a referral, and you can call to make an appointment when it is convenient for you.”
Timing of intervention. Patients who aren't ready to deal with sexual issues can ask for information in the future.
- Example: “If you have any questions, you can call my direct line and we will make an appointment to discuss these issues in greater depth. In the meantime, here is some reading material that you may find helpful.”
Education on sexual effects of treatment, which is as important as teaching about any other adverse effect.
- Example: “In addition to drying nasal passages, antihistamines can also dry vaginal tissues, leading to pain during intercourse. You may want to use a vaginal moisturizer or lubricant to help with this.”
Recording. In the patient's file, briefly note that a discussion about sexuality or sexual adverse effects took place.
- Example: “Discussed with patient the use of a local moisturizer to treat dyspareunia. Patient is going to try Replens and will report its effectiveness at next appointment or sooner if necessary.”
Mick J, et al. Oncol Nurs Forum 2003;30(2 suppl):152–3.
When a Conversation Is Difficult for You
The barriers that prevent nurses from addressing issues related to sexuality, which I described in “Do Ask, Do Tell” (Sexually Speaking, July 2005), may be especially relevant to this discussion. Most female nurses are likely to have or have had many of the symptoms of menopause as their patients. You may feel your patient's experience is too similar to your own for a conversation about symptoms to be comfortable—or you may feel that very similarity can guide you in approaching the subject and talking with your patient. If you are premenopausal, you may have difficulty understanding how menopause may change a woman's experience of sexuality. If you feel uncomfortable discussing vaginal atrophy, dyspareunia, or other issues related to menopause and sexuality with your patients, consider
- observing how an expert colleague handles such conversations.
- obtaining additional training at a workshop or online.
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2005;142(12 Pt 1):1003–13.
2. Mishra G, Kuh D. Sexual functioning throughout menopause: the perceptions of women in a British cohort. Menopause
3. Weijmar Schultz W, et al. Women's sexual pain and its management. J Sex Med
4. Willhite LA, O'Connell MB. Urogenital atrophy: prevention and treatment. Pharmacotherapy
5. Phillips NA. Female sexual dysfunction: evaluation and treatment. Am Fam Physician
6. Kovalevsky G. Female sexual dysfunction and use of hormone therapy in postmenopausal women. Semin Reprod Med
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2000;34 Suppl 1:S9-S16.
8. Dennerstein L, et al. Factors affecting sexual functioning of women in the mid-life years. Climacteric
9. van Lunsen RH, Laan E. Genital vascular responsiveness and sexual feelings in midlife women: psychophysiologic, brain, and genital imaging studies. Menopause
2004;11(6 Pt 2):741–8.
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11. Alexander JL, et al. The effects of postmenopausal hormone therapies on female sexual functioning: a review of double-blind, randomized controlled trials. Menopause
2004;11(6 Pt 2):749–65.
12. Morales L, et al. Acute effects of tamoxifen and third-generation aromatase inhibitors on menopausal symptoms of breast cancer patients. Anticancer Drugs
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14. Basson R. Rethinking low sexual desire in women. BJOG
15. Kalogeraki A, et al. Cigarette smoking and vaginal atrophy in postmenopausal women. In Vivo
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