In the era of understanding menopause, we’re challenging preconceived notions of sexual health and contraception.
In “Sexual Health and Contraception in the Menopause Journey,” Drs. Laura Cucinella and Lara Tiranini, Gynecologists, and Dr. Rossella E. Napp, Gynecologist and Endocrinologist, explore how menopause impacts women’s sexual health.
This work is essential to understanding and addressing the complexities of sexual health during menopause and examining the impact of contraception use during these life phases. They dissect the roles of genitourinary syndrome of menopause (GSM) and hypoactive sexual desire disorder (HSDD) in altering sexual health during midlife and beyond. The authors delve into the nuanced way in which hormone deficiencies during menopause interact with various determinants from a bio-psycho-social perspective.
GSM & HSDD
Genitourinary syndrome of menopause is “a collection of signs and symptoms associated with estrogen deficiency that can involve changes to the vulvovaginal area and lower urinary tract.” This condition underscores the impact of hormone fluctuations during menopause on women’s sexual and urinary health.
GSM symptoms include:
- Vaginal dryness
- Irritation
- Urinary urgency
- Discomfort during sexual activity
On the other hand, hypoactive sexual desire disorder is characterized by a persistent or recurrent deficiency of sexual fantasies or desire for sexual activity, causing marked distress or interpersonal difficulty, not accounted for by a medical, substance-related, or other psychiatric condition. The prevalence of HSDD among midlife women ranges between 14% and 33%.
Symptoms of HSDD result from an imbalance of neurotransmitters in the brain that regulate sexual behavior, where inhibitory neurotransmitters, such as serotonin and opioids, may predominate over excitatory ones, like dopamine, oxytocin, melanocortin, and noradrenaline.
These conditions can affect physical health and emotional intimacy, relationship satisfaction, and overall quality of life.
The Research
The authors reviewed studies and analyzed data to investigate the impact of different hormonal contraceptives on sexual responses in perimenopausal women, reinforcing the need for personalized treatment based on individual phenotypes and the collection of long-term safety data on treatments in high-risk populations, including breast cancer survivors.
The SWAN Study
This longitudinal, multi-site study explored physical, biological, psychological, and social changes women undergo during their middle years, particularly focusing on menopausal transitions. The SWAN study included women aged 42 to 52, emphasizing a broad demographic to capture the nuances of health changes during this period comprehensively.
The PRESIDE Study
The PRESIDE study was an extensive investigation into the prevalence of sexual symptoms and the associated stress among women. This study involved a larger sample size of 31,581 women ages 18 to 102 years.
The researchers employ the International Society for the Study of Women’s Sexual Health process of care, which proposes a simple framework for effective screening, management, and referral in both primary and specialized settings.
This model, known as POSIT, outlines a four-step model for sexual assessment:
- Permission: Getting permission from the participant for a universal screening.
- Offer Information: Giving information on menopause and how it may affect sexuality.
- Suggestions: Provide specific suggestions such as the use of lubricants, vaginal moisturizers, and counseling.
- Intensive Therapy: Making referrals for pharmacological treatments, sex therapy, and physical therapy; as needed.
The study leverages a holistic view, incorporating facts like sexual history, trauma, orientation, and the impact of menopause/aging on sexuality.
Menopause and Sexual Health
The comprehensive analysis of the studies mentioned above led the authors to several key findings related to the impact of menopause on sexual health.
The Prevalence of Sexual Symptoms: Around 50% of women in midlife report sexual symptoms. These symptoms increase with age but do not always translate into sexual dysfunction diagnosis, as distress is required for such a diagnosis.
GSM and HSDD: These conditions are prevalent and significantly impact sexuality in midlife and beyond. GSM and HSDD often overlap, affecting domains of sexuality including arousal, orgasm, and satisfaction.
Treatment of Management: The study explores treatment options, including lubricants, local estrogen therapy, and pharmacological treatments. However, it also notes the discrepancy between the availability of effective treatments, actual treatment rates, and patient satisfaction.
Contraception Across the Menopausal Transition: The authors discuss the necessity of considering contraception during menopause, speaking on the risks, benefits, and possible implications of sexual function.
Risks
- A 2011 study suggests an increased risk of venous thromboembolism with oral combined hormonal contraceptives, especially for women aged 45-49 years.
- A combined hormonal contraceptive may be associated with a slightly increased risk of breast cancer, with a relative risk of 1.20, which translates to one additional case per 7690 users a year; according to 2017 research.
- Women may have an increased incidence of cervical cancer with prolonged use of a combined hormonal contraceptive.
- There appears to be a possible mild reduction in bone mineral density with depot medroxyprogesterone acetate injections.
Benefits
- Hormonal contraceptives appear to have improved in safety and tolerability profiles, prompting their use in women over 40.
- CHCs, including pills, vaginal rings, and transdermal patches, offer short-acting reversible contraception with evolved progestogenic and estrogenic components.
- Non-hormonal methods like condoms, copper intrauterine, and permanent surgical sterilization offer an alternative for those preferring to avoid hormones.
- Extra-contraceptive benefits may include the management of menstrual irregularities, abnormal uterine bleeding, endometrial hyperplasia, dysmenorrhea, endometriosis, premenstrual syndrome, menstrual migraines, vasomotor symptoms, and the protection of bone health. They also might reduce ovarian, endometrial, and colorectal cancer risks.
Possible Implications
- Tailored contraceptive choices should consider not only the potential benefits and risks but also sexual acceptability according to women’s preferences.
- Hormonal contraception appears to positively affect sexuality by overcoming the fear of unwanted pregnancies and resolving painful or distressing gynecological conditions.
- The effect of hormonal contraception on sexuality is complex and influenced by multiple factors, including intrapersonal, interpersonal, and sociocultural elements.
- Contraception during perimenopause requires careful consideration of cardiovascular safety, especially in women with comorbidities or those who smoke.
Responsibility
In the study, the researchers address the challenges in openly discussing sexual health, especially as it pertains to menopause and sexuality. It outlines the bidirectional cultural biases between patients and healthcare providers that contribute to the stigmatization of aging women as asexual and the misconception that sexual symptoms are a normal component of aging.
The research stresses the critical role of healthcare providers in breaking down these barriers.
“Often sexual symptoms remain unspoken, and it is an HCP’s [healthcare provider’s] responsibility to be proactive and investigate sexual issues as routinely as for any other component of health.” (Dr. Cucinella et al.)
This indicates the ethical responsibility of healthcare providers to create an environment where women feel empowered to discuss their sexual health concerns without fear of judgment or dismissal.
Moving Forward
The comprehensive review underscores the critical need for individualized treatment plans to manage the diverse manifestations of menopause, acknowledging that each women’s experience is distinct due to various bio-psycho-social influences.
Dr. Cucinella and colleagues highlight the significance of addressing genitourinary syndrome of menopause and hypoactive sexual desire disorder with tailored interventions, emphasizing the importance of screening for HSDD in primary care and the safety of continuing hormonal contraception until menopause. This approach facilitates making informed choices that account for both contraceptive benefits and potential health risks. The study advocates for a proactive healthcare provider role in discussing sexual health.
“Screening of HSDD should be performed even in the primary setting, followed by a referral according to etiology/risk factors emerging in patient history.” (Dr. Cucinella et al.)
The discussion on ethical considerations in research and care emphasizes the importance of addressing the complex realities and needs of women during and post-menopause, advocating for evidence-based, patient-centered care to enhance the quality of life and sexual health standards.
