Dr. Elna Rudolph, medical doctor and sexologist, talks about the difference between menopause and perimenopause; her approach to menopause; symptoms like hot flushes, vaginal dryness, sleeping problems, weight gain and osteoporosis; how these can be treated by balancing your hormones; and the dos and don’ts of dating later in life, especially concerning talking about sex.

Sensitive content: this article contains a candid discussion of sexual function and is intended for adult readers.

“Women often ask me about the difference between menopause and perimenopause. When you reach menopause, your ovaries have stopped producing the hormones oestrogen, progesterone and testosterone. Menopause is confirmed when you haven’t had your period for a full year.
“Natural menopause usually happens between 40 and 58, with 51 years as the average. Menopause could, however, occur in your 30’s or your 60’s.
“Perimenopause involves the transitional phase between normal menstruation and menopause. The signs can include hot flushes, irregular periods, sleep disturbances, mood swings, irritability and vaginal dryness. The reason is that oestrogen levels go up and down in a completely unpredictable way.
“It could be that this month you ovulate, then for three months you don’t. Were we to take blood tests, they might show that today your oestrogen level is 1500, tomorrow it’s zero, then for three days it’s 300. Some women sail through this time and experience no discomfort; others are sensitive to the difference between an oestrogen level of 200 and one of 300. Every woman’s experience is unique. Moreover, it is impossible to say how long perimenopause will last.
“Symptoms of menopause can include hot flushes, urinary infections, incontinence, vaginal dryness, loss of sexual drive, decrease in bone density, weight changes, sleep disturbances, mood changes like anxiety or depression, and forgetfulness.”

The role of blood tests

“I’d like to explain why I’m mentioning blood tests. Medically, menopause can be approached in many different ways. Doctors following the South African guidelines are not required to describe medication based on hormone levels indicated by blood tests. Typically, a woman who suspects that she’s menopausal will visit a general practitioner, who will discuss her symptoms and prescribe medicine accordingly.
“I work in a different way, relying on blood tests. In my practice I see women who can afford to pay for an hour’s consultation, spend R1000 on a blood test, and get an individual treatment plan. The blood test is not a once-off: it needs to be repeated. Balancing hormone levels can relieve physical, sexual and other problems arising from menopause. We are fortunate to have exceptionally effective tools at our disposal.”

Menopause, hormones and sex

“Interestingly enough, testosterone levels do not suddenly drop during menopause. They gradually decline throughout your life. By the time you reach menopause, you have none left. What happens during menopause is that you lose your oestrogen as well. This is often what causes sexual problems to grow serious.”

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More about oestrogen

“I often see menopausal women when they start experiencing dryness due to a lack of oestrogen. In the preceding years they probably lost some of their desire for sex and were not as eaily aroused, but able to compensate because they still had oestrogen.  During perimenopause their oestrogen level declines until there is nothing left.

“If you look at research studies, a menopausal woman who takes oestrogen - either vaginally or systemically - is double as likely to have sex as her peer who is not taking hormones. If you’re menopausal and your GP fails to ask you whether you find sex uncomfortable and need help, your chances of having sex are reduced by half when compared to your friend whose doctor asked her about this. Take the matter into your own hands and ask for a prescription if you need to. You can get over the counter medicine, but your doctor’s prescription will be more effective. This problem needs to be treated up to the point where you are experiencing comfortable sex.”

Dryness redefined

“GSM is defined as a collection of signs and symptoms that are mainly associated with the decrease in oestrogen production during menopause. These symptoms can involve urination, sexual function, and discomfort. In other words, we are now looking at a bigger picture.

“As a woman loses her oestrogen she may get more bladder infections, need to urinate more often, ‘leak’ more easily, experience a burning sensation, or find intercourse dry and painful. Even though a woman isn’t sexually active, she may experience a burning sensation all the time. She may think it’s an infection and apply medication, which may irritate the area even more. The vaginal lining thins to the extent that the nerves are very close to the surface, which makes the area super sensitive. Using oestrogen would make a big difference and also soothe other symptoms of GSM.

“Oestrogen needn’t be absorbed systemically, which could accelerate the risk for blood clots. It can be applied topically. Oestrogen that is specially manufactured to remain in the vagina and not be absorbed throughout the body can be used by women who are cautious when it comes to using hormones.

“When we say we want to give a woman hormone therapy, the safest option is hormones which can be absorbed through the skin – either by rubbing a gel onto the upper arm, or by using a patch. Both are examples of systemic oestrogen. However, about one third of all women using systemic oestrogen still experience vaginal dryness. The hormones entering their blood stream do not reach and fully impact on the genital area. This means that a woman already using a patch may also need a vaginal cream or tablet.

“If you take a woman without any oestrogen and give her some, it improves her libido. Women with no oestrogen have a far bigger chance of experiencing low libido.

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What you need to know about testosterone

“In South Africa, testosterone has not been registered for use by women. It needs to be compounded - to be specially manufactured. If you need it, it is extremely important to find a reputable, trustworthy source. I always use the same firm because I know the quality of their product.

“I regularly treat transgender people and know that if I give a woman enough testosterone, I can transform her into a man. This can be dangerous. You need to know what you are doing, and your patient needs to realise that this is an off-label treatment and understand the potential risks.

“However, if you do this correctly, it is safe and wonderfully effective. Nothing else works as well to boost a woman’s libido. I literally have thousands of patients on this treatment.”

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“Remember that this requires blood tests: testosterone must be administered in a dose that takes into consideration your specific requirements and the way your body reacts to it. It really is an art. Some women require higher doses. We start with a blood test, and I’ll need to do another in six weeks. This routine may need to be repeated three or four times.

“I always consider aspects such as a patient’s cholesterol and sugar levels and blood pressure, history, family history, and lifestyle. Lifestyle is exceedingly important. We talk about the risk of breast cancer associated with hormone therapy, mammograms, bone density and so on. I give a patient all the information and outline all the options so that she can make an informed decision.”  

Sleep disturbances, joint pains and weigh gain

“Some women are anxious, which may also have to do with a progesterone imbalance.

“Then there are patients who experience joint pains. These can usually be remedied by sorting out any hormone imbalances.

“Some menopausal women gain weight. This could be because the loss of hormones has suppressed their thyroid function and it has become underactive. In other cases, they may have developed depression as part of menopause, which has caused  them to eat more and put on weight. They may have exercised less often due to painful joints, been working too hard to find time for exercise, or simply have grown lazy. There are many possible reasons for weight gain, but my job is to see whether it’s hormone-related and address this.  

“I see menopausal women with irritable bowel syndrome or a problem with chronic itching, which can both be improved.

“The serious side of menopause is osteoporosis. If you have gone without hormones for a long time, especially if there are other risk factors such as consuming too much alcohol or using steroids for asthma, getting osteoporosis can be very serious indeed.”

Problems in the bedroom

“Of course, the patients who come to see me usually have problems concerning sexual functioning. During menopause this can involve relationship problems, a partner’s erectile dysfunction - meaning that intimacy may have stopped altogether, or painful sex which makes penetration impossible. There can also be a range of emotional difficulties; for instance, when a woman has gained 10 kg since entering menopause, she may find it more difficult to be naked around her partner.

“Another challenge involves lichen sclerosus, a skin condition which renders the entrance to the vagina painfully sensitive. A woman may think it’s only a case of candida and try to treat it with the help of over the counter medicine, when in fact she is suffering from a serious condition.”

Sex and relationships later in life

“When you’ve reached your fifties, you should be mature enough to have an adult conversation. No matter how nice, wealthy, respectable or ‘clean’ your new partner looks, there are risks involved! You need to test for HIV, syphilis and hepatitis B. Make a joint appointment at the GP’s, say you’re starting a new relationship, and ask to be tested.

“Another very important matter is that many women think they’re in menopause – and then fall pregnant. Perhaps they were married before and used contraception, then they were celibate for a couple of years, and now at, say, 47 they start having sex again and fall pregnant. You can even fall pregnant at 55 – this is highly unlikely, but definitely possible. You and your partner need to discuss the matter.

“As a mature adult, you enjoy the luxury of having sex according to your wishes – and to communicate about it beforehand! Some people are liberated enough to have one-night stands, which does not necessarily involve any communication. But most couples meet each other through friends or in other ways, and the relationship develops gradually.

“In this case, you should be able to communicate openly about sex long before you get into bed. You should feel comfortable enough to tell your partner what you expect and what your preferences are. If you’re not able to, this may tell you something about the relationship and how difficult conversations may fare in the future you’re going to share.

“This is the ideal opportunity to discuss your views on contraception, foreplay, what you find acceptable, the possible need for lubrication, and who is responsible for what.

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“In my experience, the biggest relationship challenges during this phase of life are children, properties, parents-in-law, and issues like finances and holidays. It’s much more complex than when two young people get together.

“If there is a sexual problem, please get medical help. Perhaps you haven’t had sex in five years and inserting a tampon into your vagina when you have your period is a bit of a struggle. In this case, you and your partner need to take it slowly! Don’t just forge ahead because you’re feeling awkward. If you do and it doesn’t work out, you’ll be facing bigger problems. The more honest you can be from the word go, the smaller the chance of failure.”

Single women

“Some menopausal women feel enough is enough and are happy never allowing a man into their bed again. However, the patients I see usually have sustained their interest in sex, even without a partner. The principle that applies is: if you don’t use it, you lose it.

“Even if you don’t have a partner, use vaginal oestrogen. When you’re in the bath tub or shower, make sure that you’re able to insert two fingers into your vagina, especially if you don’t masturbate. From my point of view there’s no reason not to have solo sex, if this complies with your religious outlook.

“Finally, if you’re older and in a new relationship, remember that sex is a little like riding a bicycle. If you know how to ride a bicycle you can resume it at 80, even if you haven’t done it for years. You needn’t ride competitively – you can take a leisurely ride in the park.

“Keep your options open. Women can be perfectly happy on their own, but some meet their great love later in life.” 

Contact details

Dr. Elna Rudolph is a medical doctor, sexologist and the clinical head of My Sexual Health, die biggest multidisciplinary team of Sexual Health Professionals in South Africa with offices in Johannesburg, Pretoria and Cape Town. Dr. Rudolph is the President of the World Association for Sexual Health (WAS) and is involved in the Southern African Sexual Health Association (SASHA).

Tel. 011 568 4844

www.DrElnaRudolph.com
www.MySexualHealth.co.za
Facebook Dr. Elna Rudolph – Sexologist
Instagram: @sexologistmom

This article was based on an Afrikaans podcast interview Mariette recorded for rrRADIO, the podcast platform of rooi rose.

Images: Unsplash, unless specified otherwise. Models were used.