It’s Never Too
Late: Sexual
Health After
Menopause
Dustin J. Stehling, MD, OB-Gyn
www.SpringfieldClinic.com
Is Sex Better after Menopause?
•
•
•
•
•

You cannot get pregnant
Fewer interruptions
You know what you want
You have an e...
New Partner - Safe Sex!
• No Ovulation; Had a hysterectomy
–

Sexualy transmited infections (STI’s) are on
the rise in pos...
Condom Use
• Prevents the transfer of most STI’s
–
–
–
–
–
–

Gonorrhea
Chlamydia
Trichomonas
HIV
Syphilis
Hepatitis
You can be Tested
• Screening can be done with for all of
these infections
–
–

Blood sample and vaginal swabs required
Ta...
HPV:

Human Papillomavirus

• Causes genital warts and cervical
cancer
• Transmitted through sexual contact
• Unclear what...
Problems with Sex
• ~40% of women have concerns with sex
• 12% have distressing sexual problems
• These issues come in dif...
Risk Factor
• Often from multiple sources
–
–
–
–
–
–
–

conflict within the relationship
fatigue and stress
physical prob...
Fixing the “Problem”
• No magic bullet.
• Many times there is more than one
source for the issue.
• You have to be honest ...
Treatment: may include
•Changes in current medication
•Counseling
–Personal
–Relationship

•Treating depression or anxiety...
Hormone Production After
Menopause: Ovaries
• Estrogen reduces dramatically
–
–
–

Less vaginal lubrication
Less blood flo...
Replacing Testosterone:
• We do not check testosterone levels
• Can improve –
–
–
–

Sexual desire
Sexual responsiveness
S...
Replacing Testosterone:
• We do not check testosterone levels
• Can improve –

Sexual desire, responsiveness, arousal,
and...
Replacing Testosterone:
Adverse Effects
•
•
•
•
•

Extra hair growth
Acne
May worsen cholesterol
Uncertain risk for breast...
Replacing Testosterone:
Contraindications
•
•
•
•

Heart disease
Liver disease
Uterine cancer or hyperplasia
Breast cancer
How to Replace Testosterone
•No marketed formulation in the USA for
women.
–Products designed for men are about 10x
too st...
Who Should be Treated
•Hypoactive sexual desire disorder
–Low or absent sexual fantasies
–Low or absent desire for sexual ...
Monitoring Testosterone Therapy
• Cholesterol and liver panels
–Prior to starting
–After 6 months
–Annually
• Exams to loo...
ESTROGEN
Replacing Estrogen: Oral
• Women’s Health Initiative (WHI)
–
No direct improvement in sexual
satisfaction
–
Treatment may ...
Replacing Estrogen: Oral
• Concern (Risk)
–
–
–
–
–

Coronary heart disease
Stroke
Venous thromboembolism (blood clots)
Br...
Vaginal Atrophy
Vaginal lining with estrogen

Vaginal lining in low-estrogen state
Replacing Estrogen: Vaginal
• Most effective treatment for moderate to
severe symptoms of vaginal atrophy
–
–
–
–

Restore...
How to Replace Vaginal Estrogen
•Many different forms
–Tablet (Vagifem®)
–Ring (Estring® or Femring®)
–Cream (Premarin® or...
What about Harm?
•This is not just for recently menopausal
women
–Low dose vs. high dose therapy

•No studies looking at r...
Other Options for Vaginal Atrophy
•Increased sexual activity
•Lubricants
•Vaginal Moisturizers
•Ospemifene (Osphena®)
Increasing Sexual Activity
•Either with your partner or through
masturbation
–Studies have shown women with higher
frequen...
Vaginal Moisturizer
•Intended for scheduled use
•Provides relief of vaginal dryness and
restoration of normal vaginal pH
•...
Vaginal Lubricants
•Can be used to supplement other
treatment or alone for mild symptoms.
•Used with every sexual encounte...
Painful Sex
• Common problem
• Many causes; often multiple sources at
once
• Talk about it!
–
–

with your partner
with yo...
Partner Problems
•Often these can be fixed
–Relationship
–Stress/fatigue
–Erectile dysfunction (ED)
Take Home Message:
•Sex is safe and healthy after menopause
–Enjoy it! But be safe.

•Do not be afraid to talk about probl...
More Resources

Thank you!
Find videos, handouts and more

www.SpringfieldClinic.com/DoctorIsIn
It’s Never Too Late: Sexual Health After Menopause
It’s Never Too Late: Sexual Health After Menopause
It’s Never Too Late: Sexual Health After Menopause
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It’s Never Too Late: Sexual Health After Menopause

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According to recent studies, people over 50 are having more sex than ever. But with that news comes a downside: the rate of sexually transmitted diseases has doubled among that age group. Safe sex isn’t just for the young—it’s for everyone. Consider this your sex ed refresher course—with a twist. Dr. Dustin Stehling discusses sexual health after menopause—dealing with the changes in your body, staying healthy and enjoying your post-menopausal life.

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  • The details of each of these is a topic for discussion alone; but we will touch on these.
  • A thorough history and on occasion physical exam is required to identify the specific cause or causes leading to sexual dysfunction.
  • BSO causes a 40-50% drop in serum testosterone concentration
  • Levels of endogenous androgens do not predict sexual function. studies looking at androgen concentarations and sexaual function has either a weak correlation or is nonexistent.
    Useful for women with BSO and HSDD or some postmenopausal women with decreased sexual desire with personal distress and no other identifiable cause. **This is not recommended for routine use but for women with HSDD failing nondrug therapy, a trial of testosterone therapy is reasonable.
  • Levels of endogenous androgens do not predict sexual function. studies looking at androgen concentarations and sexaual function has either a weak correlation or is nonexistent.
    Useful for women with BSO and HSDD or some postmenopausal women with decreased sexual desire with personal distress and no other identifiable cause. **This is not recommended for routine use but for women with HSDD failing nondrug therapy, a trial of testosterone therapy is reasonable.
  • This is not a magic fix to all sexual problems. It should be used in selected situations after thoughtful and thorough conversation with your Dr.
    Effects on cholesterol is more of an issue with oral therapies.
    Testosterone is converted to estrogen in the body. This overall increases estrogen and can increase risk for breast and uterine cancer (PMB).
  • Dr Should check cholesterol and liver labs prior to starting, at 6 months then annually.
    Patient should be aware to contact Dr if ever feels a breast lump, has PMB and should have annual mammogram.
    Checking free testosterone level while under treatment may be good also to make sure not pushing levels above “normal” range for premenopausal women.
  • This study looked at 27,000 postmenopausal women in conjunction with HRT.
    Orally administered, whole body, HRT does not improve sexual satisfaction but may place the patient in harm.
    If menopausal symptoms are impacting sexual function, this treatment may be warranted. But this is an indirect improvement of sexual function. Quality of life improvement!
  • This is a very complex and deep topic that requires far more time that we have tonight.
    Basics - Low dose therapy for short duration (<5 years) is safe in women entering menopause (late 40’s to early 50’s) without significant risk factors.
    Each of these “risks” depends on age, underlying health status, and which hormones are being used.
  • low doses of estrogen replacement can be used by this method with infrequent dosing intervals, but still allowing improvement of symptoms.
    potential risks of this low dose approach have not been evaluated but the risks discussed with the oral HRT are felt to be possible but unlikely.
  • It is ok to bring this up during your annual exam, but it often takes more time to discuss then is allocated for an annual visit. Be prepared to make a second appointment after bringing it up. Consider making an appointment specifically for this. Do not be afraid to tell the nurse scheduling the appointment why you want to come in. Don’t make up a fake reason to come in with the intention to talk about this instead. Your Dr needs to be ready to discuss this and have the intention to give you the time need to discuss this problem.
  • It’s Never Too Late: Sexual Health After Menopause

    1. 1. It’s Never Too Late: Sexual Health After Menopause Dustin J. Stehling, MD, OB-Gyn
    2. 2. www.SpringfieldClinic.com
    3. 3. Is Sex Better after Menopause? • • • • • You cannot get pregnant Fewer interruptions You know what you want You have an excuse to try new things Less stress/worries about job and finances
    4. 4. New Partner - Safe Sex! • No Ovulation; Had a hysterectomy – Sexualy transmited infections (STI’s) are on the rise in postmenopausal women • Condoms are still required!
    5. 5. Condom Use • Prevents the transfer of most STI’s – – – – – – Gonorrhea Chlamydia Trichomonas HIV Syphilis Hepatitis
    6. 6. You can be Tested • Screening can be done with for all of these infections – – Blood sample and vaginal swabs required Talk with your doctor • Your partner can also be tested – Ask for proof of testing
    7. 7. HPV: Human Papillomavirus • Causes genital warts and cervical cancer • Transmitted through sexual contact • Unclear what effect condoms have on transmission • There is a test for this virus – Pap smear guidelines have changed recently
    8. 8. Problems with Sex • ~40% of women have concerns with sex • 12% have distressing sexual problems • These issues come in different forms – – – – lack of sexual desire impaired arousal inability to achieve orgasm pain
    9. 9. Risk Factor • Often from multiple sources – – – – – – – conflict within the relationship fatigue and stress physical problems lack of privacy depression or anxiety medications history of abuse
    10. 10. Fixing the “Problem” • No magic bullet. • Many times there is more than one source for the issue. • You have to be honest with • Yourself • Your partner • Your Doctor
    11. 11. Treatment: may include •Changes in current medication •Counseling –Personal –Relationship •Treating depression or anxiety •Life style changes •Hormone replacement
    12. 12. Hormone Production After Menopause: Ovaries • Estrogen reduces dramatically – – – Less vaginal lubrication Less blood flow to vagina and clitorus Decrease libido and sexual responsiveness • Androgens (testosterone) “stays steady” – – Production decreases throughout life This drop slows around menopause
    13. 13. Replacing Testosterone: • We do not check testosterone levels • Can improve – – – – Sexual desire Sexual responsiveness Sexual arousa Orgasmic response
    14. 14. Replacing Testosterone: • We do not check testosterone levels • Can improve – Sexual desire, responsiveness, arousal, and orgasmic response • Limited data on safety and usefulness – Especially long-term • No androgen therapy is FDA approved for treating female sexual dysfunction
    15. 15. Replacing Testosterone: Adverse Effects • • • • • Extra hair growth Acne May worsen cholesterol Uncertain risk for breast cancer Postmenopausal bleeding
    16. 16. Replacing Testosterone: Contraindications • • • • Heart disease Liver disease Uterine cancer or hyperplasia Breast cancer
    17. 17. How to Replace Testosterone •No marketed formulation in the USA for women. –Products designed for men are about 10x too strong for women. •Products can be compounded as gels to apply to the skin (arm, leg or abdomen) •Given as a shot (in the muscle) at your doctor’s office.
    18. 18. Who Should be Treated •Hypoactive sexual desire disorder –Low or absent sexual fantasies –Low or absent desire for sexual activity •Must be recurrent or persistent •Must cause personal distress or interpersonal difficulty •After ruling out all other causes
    19. 19. Monitoring Testosterone Therapy • Cholesterol and liver panels –Prior to starting –After 6 months –Annually • Exams to look for adverse effects • Clinical/self breast exams. Mammography • Measuring free testosterone level
    20. 20. ESTROGEN
    21. 21. Replacing Estrogen: Oral • Women’s Health Initiative (WHI) – No direct improvement in sexual satisfaction – Treatment may be harmful • Has impact on menopausal symptoms – Hot flashes, night sweats, sleep disruption, and fatigue • Must give with progesterone if you still have your uterus
    22. 22. Replacing Estrogen: Oral • Concern (Risk) – – – – – Coronary heart disease Stroke Venous thromboembolism (blood clots) Breast cancer Dementia
    23. 23. Vaginal Atrophy Vaginal lining with estrogen Vaginal lining in low-estrogen state
    24. 24. Replacing Estrogen: Vaginal • Most effective treatment for moderate to severe symptoms of vaginal atrophy – – – – Restores the normal vaginal environment Thickens the vaginal tissue Increases vaginal secretions Decreases vaginal dryness
    25. 25. How to Replace Vaginal Estrogen •Many different forms –Tablet (Vagifem®) –Ring (Estring® or Femring®) –Cream (Premarin® or Estrace®)
    26. 26. What about Harm? •This is not just for recently menopausal women –Low dose vs. high dose therapy •No studies looking at risk specifically with these medical therapies
    27. 27. Other Options for Vaginal Atrophy •Increased sexual activity •Lubricants •Vaginal Moisturizers •Ospemifene (Osphena®)
    28. 28. Increasing Sexual Activity •Either with your partner or through masturbation –Studies have shown women with higher frequency of intercourse have fewer symptoms related to vaginal atrophy •Average 2.5 x a week vs. 1 time a month •Benefit likely comes from mechanical stretching of the vaginal tissue and increased blood flow to the area.
    29. 29. Vaginal Moisturizer •Intended for scheduled use •Provides relief of vaginal dryness and restoration of normal vaginal pH •Useful for mild symptoms of vaginal atrophy •Many products found over the counter
    30. 30. Vaginal Lubricants •Can be used to supplement other treatment or alone for mild symptoms. •Used with every sexual encounter •Not all are created equal –There are different forms –Some provide additional benefits
    31. 31. Painful Sex • Common problem • Many causes; often multiple sources at once • Talk about it! – – with your partner with you gynecologist
    32. 32. Partner Problems •Often these can be fixed –Relationship –Stress/fatigue –Erectile dysfunction (ED)
    33. 33. Take Home Message: •Sex is safe and healthy after menopause –Enjoy it! But be safe. •Do not be afraid to talk about problems •Be open minded about new interventions •There is not one fix for all problems •If your doctor does not bring it up…YOU SHOULD!
    34. 34. More Resources Thank you! Find videos, handouts and more www.SpringfieldClinic.com/DoctorIsIn

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