How Menopause Affects Intimacy and Sexual Health: A Q&A with Dr. Gillian Goddard

In the last few years menopause has been having a moment. With the recent attention of celebrities like Naomi Watts and Halle Berry, women are feeling freed to talk about their hot flushes, their night sweats and their inability to recall proper nouns. Along with that women are sharing their experience with sex and the challenges menopause introduces in our intimate relationships.

Dr. Goddard is a practicing endocrinologist, and the author of the popular newsletter Hot Flash and the forthcoming book The Hormone Loop. In this Q&A we discuss the hormone shifts women experience in menopause and how those shifts can affect how we experience intimacy and sex during the perimenopausal transition.

Q&A with Dr. Gillian Goddard about intimacy and sex in menopause. 

Background and expertise

How did you become interested in women’s health in midlife?

Thank you so much for inviting me to share my expertise with your audience. When we think about the issues we classically associate with therapy, hormones don’t always spring to mind. But so many of the chemicals in our brain that affect our mood and perception of the world are hormones like dopamine, serotonin, and cortisol. So I think the connection between psychology and endocrinology is an important one. 

I have always had an interest in women’s health specifically. I briefly considered a career in obstetrics and gynecology, but I quickly discovered that endocrinology — that is the study of all the hormones including reproductive hormones like estrogen and progesterone — allowed me to come at women’s health from a different angle. As I built my practice many of my patients were women my age and in the last five years or so my patients, like me, have been experiencing perimenopause and menopause in greater numbers.

As hormone experts, endocrinologists are uniquely positioned to treat perimenopause and menopause. And unlike most ob/gyns who get little training in menopause care, endocrinologists are trained in prescribing hormone therapy because we are the doctors who have always treated premature ovarian insufficiency (or POI, what we used to call premature menopause, or menopause before age 40). Even in the years following the publication of the Women's Health Initiative study, when doctors in general were avoiding prescribing hormone therapy, endocrinologists were still treating women with POI because for women POI hormone therapy was still recommended. 

What is one piece of information all women should know?

The transition perimenopausal has stages. When we talk about perimenopause and menopause we tend to get a little sloppy with our language, especially on short social media clips. But a lot of the confusion that happens between women and their doctors results from a language barrier. 

Imagine a woman in her early 40s goes to her doctor and says, “I am having these three symptoms. Am I in perimenopause?” Her doctor asks her a single question: Are your periods regular? When the woman answers yes, her doctor says the woman isn’t in perimenopause and moves on. The woman has not yet had her symptoms addressed. 

In fact, that woman was probably in a stage called the late-reproductive stage which is sort of a bridge between our reproductive years and perimenopause. Many women have symptoms that can be treated during the late-reproductive stage.

After the late reproductive stage comes early perimenopause when periods become irregular. Then late perimenopause, when women will go more than 60 days without having a period. Then women have their last menstrual period (though at the time they can’t know it s the last one) and enter early menopause which last three to five years and then menopause. 

The reason these stages are important is because it helps us to communicate with one another and because symptoms can vary as women move from stage to stage.  

Perimenopause, menopause, and intimacy

How do perimenopause and menopause affect women’s intimate relationships?

There are a number of ways the perimenopausal transition and menopause affect women’s intimate relationships. Over the course of perimenopause and menopause estrogen level drop. Estrogen keeps the walls of the vagina moist and plump. When estrogen levels fall the lining of the vagina thins and women can get vaginal dryness that can make sex uncomfortable.

Many women experience mood changes in perimenopause and menopause. Anxiety, depression, and irritability are all common. We all know how much mood changes can affect our desire for intimacy and sex, and how connected we feel to our partner. 

We don’t know as much as we should about women’s sexual desire and arousal, but we think testosterone plays an important role. In perimenopause and menopause testosterone levels can dive. We think this can lead to lower libido and decreased arousal.

Do all women experience these symptoms?

Certainly there are some women who don’t find their sex lives much disrupted by perimenopause. But, depending on which symptoms you ask about, nearly two-thirds of women note sexual symptoms in perimenopause and menopause. Upwards of one-third of women note that changes in their desire for sex or arousal cause them distress or lead to problems in their relationship with their partner. 

The classic symptoms of perimenopause and menopause tend to get better within about five years of a woman’s last menstrual period. Sexual symptoms are a little different. Vaginal dryness, if left untreated, can actually get worse over time. Despite that (or perhaps because they are getting treated) many women report increased satisfaction with their sex lives in their 60s and beyond. 

When should you talk to your doctor about your symptoms?

If you are having symptoms of vaginal dryness or changes in mood it is reasonable to see your doctor right away. Try to be specific about when the symptoms started and how they are affecting your daily life. 

When it comes to low libido our issues with arousal women can ask themselves two questions. First, are they upset about the change or is it causing stress between them and their partner? And how long has it been going on? If your libido is low and it doesn't bother you or your partner then you don’t have a problem. But you have to be honest with yourself.  

Technically, to meet the criteria for hypoactive sexual desire disorder (the medical term for low libido or decreased arousal) symptoms should be present for at least six months. I find most women are tolerating symptoms for too long, not going to see their doctor too soon. 

Not all doctors are comfortable with treating perimenopause and menopause how can you find one that is?

Most people first discuss their symptoms including sexual symptoms with their gynecologist or primary care doctor. Unfortunately, doctors in both of those disciplines get little to no training in treating perimenopause and menopause. Some PCPs and GYNs have sought out additional education in managing the symptoms that come up during the perimenopausal transition including sexual symptoms. It is reasonable to start there.

If your doctor isn’t comfortable with managing perimenopause and menopause you can look for a NAMS certified provider. These are providers who have gained a certification from The Menopause Society by getting extra education in perimenopause and menopause specific treatment. You can also look for an endocrinologist like me, but depending on where you are in the country, we can be in short supply.  

Managing symptoms

Does hormone therapy help manage women’s sexual symptoms?

This is one area where one size doesn’t fit all. If your sexual symptoms stem from vaginal dryness, estrogen can definitely help. Estrogen applied directly to the vagina as a cream of pill can plump up vaginal tissue and increase vaginal lubrication. Some women will need vaginal estrogen even if they use other hormone therapy. The good news is that vaginal estrogen is safe for nearly all women, even some women with a personal history of breast cancer.

If sexual symptoms are related to libido estrogen and progesterone are unlikely to help. But this is where testosterone can come into play. Testosterone has been shown to increase the number times a woman with hypoactive sexual desire disorder has a satisfying sexual encounter. 

The challenge with testosterone is that there is no testosterone approved by the FDA for women. That has two important implications. First, the testosterone that is available isn’t dosed for women, and second it isn’t covered by insurance. Women get around this by taking a tiny dose of testosterone made for me or getting a compounded testosterone formulation from a special pharmacy. In both cases they are paying out of pocket. 

Any last words of wisdom?

All women deserve to have their symptoms addressed. As a physician, I know that doctors are people, we have good days and bad days like everyone else. If you have an unsatisfactory encounter with your doctor once it is reasonable to overlook it, especially if you have known them for a long time. But if you feel like your doctor isn’t addressing your concerns repeatedly, it may be time to look for a new provider. 

Looking for support

Dr, Goddard sees patients in her New York office where she helps women manage a broad array of hormonal issues from puberty through menopause. You can schedule a consultation by calling 212-772-7628. She writes about women’s hormone health including many issues affecting women in perimenopause and menopause in her twice weekly newsletter Hot Flash and her book The Hormone Loop is available for preorder wherever books are sold.