September is Healthy Aging Month! In recognition, this blog will talk about Menopause and how it can affect your genitals and sexual function.

What Happens During Menopause?

Menopause marks the end of the regular menstrual cycle and the transition to life beyond the reproductive period.

Babies born with female anatomy have a set number of eggs which are stored in their ovaries. The ovaries make the hormones estrogen and progesterone, which control monthly periods and ovulation. Menopause happens when ovaries no longer regularly release an egg every month and menstruation stops.

The age menopause starts can vary, but usually it is after the age of 40. Some people can go through menopause early, usually after a hysterectomy, damage to the ovaries, and sometimes from chemotherapy.

Menopause Symptoms Can Affect Quality of Life

More than 80% of those with menopause report physical and psychological changes the period before, during and after the last menstrual cycle with 77% of respondents experiencing changes in their genitals (vulva, vagina, pelvic floor) that affected their lifestyle, emotional well-being, and sexual function.

Genitourinary Syndrome of Menopause (GSM): Common Menopause symptoms that affect the genitals

Genitourinary syndrome of menopause (GSM) is a relatively new term that describes the different genital, sexual, and urinary signs and symptoms that can occur during menopause.

Here are the common symptoms of GSM (Portman, 2014):

• Vaginal dryness
• Pain with sex
• Loss of elasticity and thinning of tissues, including genitalia, urethra, etc.
• Loss of muscle mass, including the pelvic floor muscles
• Vaginal soreness
• Vaginal itching
• Vaginal burning
• Pain during urination
• Bleeding during intercourse

Other common symptoms that affect quality of life:

• Hot flashes
• Night sweats
• Disrupted sleep
• Weight gain
• Mood Swings
• Joint pain
• Headaches

Layered on top of the changes that happen with menopause are other underlying issues that existed before the onset of menopause like pelvic floor dysfunction, orthopedic dysfunction, vulvodynia, pelvic organ prolapse, urinary incontinence, and bowel issues including chronic constipation and IBS. An existing pelvic floor issue with some menopause sprinkled on top can contribute to aggravation of symptoms and reduced quality of life.

Things you can do to support pelvic health and sexual function after Menopause

Use it or Lose it: Maintain Sexual Activity

Maintaining some regularity in your sexual activity, including partnered sex or masturbation, will stimulate vaginal, vulvar, and genital tissues and help maintain sexual function. Use of dilators, vibrators, and penetrative sex will stimulate and stretch the vulvar and vaginal tissues to maintain function. Sexual arousal will increase circulation to the genital tissues, and orgasm will help circulate blood and lymphatic fluid out of the pelvic bowl also.

Lubricants and Moisturizers

Lubricants can be used as needed for sexual activity to increase comfort and pleasure. Check out our prior blog post on lubes to help you choose a lube that won’t damage your tissues.

Lube can:

• Be used for penetrative and non-penetrative sex, masturbation, and sex toy play
• Improve lubrication, pleasure, and moisture
• Decrease friction and discomfort
• Decrease failure of sexual barriers (IF COMPATIBLE, more on that later)
• Takes some pressure off the body to “perform” and create enough moisture
• Makes sexual activities possible for many folks

Common types of lubricants: oil, water-based, and silicone

Water-based lubes

Ideal for people with sensitive skin or vaginal irritation and are safe to use with condoms and sex toys. However make sure your lube has proper osmolality and pH level (read below). Water-based lubes tend to get "sticky" and you may need to re-apply if you are engaging in sex for a long time.

Silicone-based lube

Very slippery and long lasting and is safe to use with condoms. However, silicone-based lubes cannot be used with silicone sex toys, as they can damage the toy. Silicone-based lubes may be more difficult to wash off skin than water-based and may stain sheets, so keep that in mind.

Oil-based lube

We like to recommend organic coconut oil. Oil based lubes are slippery and last longer than water-based lubes. However, oil based lubes are not compatible with latex condoms, as they make the condoms easier to break. Like silicone-based lube, oil-based can stain sheets and be harder to wash off than water-based lube.

Vaginal Moisturizers

Long-term vaginal moisturizers are designed to be used daily or every few days on a regular basis to maintain vulvar and vaginal moisture. These moisturizers are designed to mimic normal vaginal secretions. Read our blog on the importance of picking the right pH and osmolality of lubricants and moisturizers to make sure your lube/moisturizer is not damaging your tissues.

Check out this chart published by the World Health Organization (WHO) listing brand names of lubricants and moisturizers and the pH levels and osmolalities of each product.

Topical lidocaine

Consult with your doctor to see if a genital-safe lidocaine gel or ointment could help with your pain with sex. Lidocaine temporarily numbs whatever it comes in contact, so it may help reduce pain at the opening of the vagina. However, be aware that lidocaine may affect the sensation of your partner as well.

Pelvic Floor Physical therapy

A pelvic floor physical therapist can help break the muscle tension cycle with manual therapy and teach you self-treatment to maintain gains at home. By releasing pelvic floor tension, you free pelvic floor muscles, allowing for pain free sex. Pelvic floor therapists can also screen for musculoskeletal dysfunction in the spine, hips and pelvis; educate about sexual ergonomics and help you find positions that reduce pain during intercourse. Pelvic floor therapists can also provide you with self care programs which can reduce dryness and irritation in the tissues of the vulva, labia, and vaginal canal.

Photobiomodulation

This year, there has been some research published by Lanzafame et al. showing that photobiomodulation, a type of light therapy using light-emitting diodes (LEDs) or supraluminous diodes (SLDs) with red and near-infrared radiation (NIR) light can be effective in the treatment of vaginal tissue laxity.

The research suggests that PBMT stimulates collagen and elastin production in the vaginal tissue and supporting urethrovaginal sphincter and urethra, which may help with symptoms of GSM. At Femina PT, we have several light therapy machines that can be used for photobiomodulation therapy.

Specific Diets that Have been Found to Positively Affect Female Sexuality

The Mediterranean diet has been shown in a few studies to improve sexual function, specifically for women who also have obesity, diabetes, and metabolic syndrome (Esposito, 2007; Towe, 2019).

In Esposito’s 2007 study, participants were asked to adhere to a Mediterranean diet for 24 months with the following guidelines:
Diets were compromised of

• 50-60% complex carbohydrates
• 15-20% of proteins -less than 30% total fats
• less than 10% saturated fats

Subjects consumed at least 250–300 g of fruits, 125–150 g of vegetables and 25–50 g of nuts per day. Additional guidelines included consuming 400 g of whole grains daily (legumes, rice, corn and wheat) and to increase the consumption of olive oil. Women were also advised to increase consumption of fish and to reduce intake of red or processed meat.

By the end of the 24 month trial, those following the Mediterranean diet in the Esposito study reported better sexual function in the areas of sexual desire, arousal, orgasm and pain.

The Ketogenic diet is described by the National Cancer Institute as a “diet high in fat and low in carbohydrates (sugars) that causes the body to break down fat into molecules called ketones. Ketones circulate in the blood and become the main source of energy for many cells in the body.”

In Castro’s 2018 study, women placed on a low calorie ketogenic diet for 4 months reported improved sexual function in the realms of arousal (excitation) and lubrication. The study also reported that some women reported improved orgasmic function.

As pelvic floor physical therapists, it is outside of our domain to prescribe or counsel people through diet changes. Please check in with your doctor, a registered dietician, and/or a licensed clinical nutritionist for more information.

For all other questions and to schedule a visit, give the therapists at Femina Physical Therapy a call today!

Resources

Aversa A, Bruzziches R, Francomano D, et al. Weight loss by multidisciplinary intervention improves endothelial and sexual function in obese fertile women. J Sex Med 2013;10:1024- 1033.

Castro A, Gomez-Arbelaez D, Crujeiras A, et al. Effect of a very low-calorie ketogenic diet on food and alcohol cravings, physical and sexual activity, sleep disturbances, and quality of life in obese patients. Nutrients 2018;10:1348.

Esposito, K., Ciotola, M., Giugliano, F. et al. Mediterranean diet improves sexual function in women with the metabolic syndrome. Int J Impot Res 19, 486–491 (2007). https://doi.org/10.1038/sj.ijir.3901555

Towe, M., La, J., El-Khatib, F., Roberts, N., Yafi, F. A., & Rubin, R. (2019). Diet and Female Sexual Health. Sexual Medicine Reviews. doi:10.1016/j.sxmr.2019.08.004

Mayo Clinic, Metabolic Syndrome

https://www.mayoclinic.org/diseases-conditions/metabolic-syndrome/symptoms-causes/syc-20351916

Trompeter, S. E., Bettencourt, R., & Barrett-Connor, E. (2016). Metabolic Syndrome and Sexual Function in Postmenopausal Women. The American Journal of Medicine, 129(12), 1270–1277.e1. doi:10.1016/j.amjmed.2016.03.039

Callan, N. G. L., Mitchell, E. S., Heitkemper, M. M., & Woods, N. F. (2018). Constipation and diarrhea during the menopause transition and early postmenopause. Menopause, 25(6), 615–624. doi:10.1097/gme.0000000000001057

Castellani, D., Saldutto, P., Galica, V., Pace, G., Biferi, D., Paradiso Galatioto, G., & Vicentini, C. (2015). Low-Dose Intravaginal Estriol and Pelvic Floor Rehabilitation in Post-Menopausal Stress Urinary Incontinence. Urologia Internationalis, 95(4), 417–421. doi:10.1159/000381989

Maltais ML, Desroches J, Dionne IJ. Changes in muscle mass and strength after menopause. J Musculoskelet Neuronal Interact. 2009;9(4):186-97

Minkin, M. J., Reiter, S., & Maamari, R. (2015). Prevalence of postmenopausal symptoms in North America and Europe. Menopause, 22(11), 1231–1238. doi:10.1097/gme.0000000000000464

Mehta, R. S., & Staller, K. (2018). Menopausal transition and bowel disturbances. Menopause, 25(6), 589–590. doi:10.1097/gme.0000000000001110