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Menopausal vulvas are rather unpopular. We don’t speak of them, don’t think of them—we don’t know anything about them. When I bring them up, I am confronted with perplexed, confused, and oftentimes disgusted looks. It is difficult enough to talk about sexuality and genitalia, so when it comes to postmenopausal (or even post-andropausal!) genitalia... Forget it! That seems to be truly subversive.
Are we really so obsessed with the cult of youth that we refuse to recognize the importance of discussing our reproductive organs after they have retired from their primary function?
Are we really so uncomfortable with the female body that we are unable to accept a concept as simple as the ever-evolving vulva?
In any case, we owe it to ourselves to acknowledge the taboo that surrounds the genital changes brought on by menopause, as well as the physical, psychological, and emotional effects thereof on women, so that we can be more supportive during an often difficult time in women’s lives (Erbil, 2017; Pearce et al., 2014).
When You Can No Longer Press (meno)Pause
Menopause is defined as the cessation of ovarian follicular activity resulting in the termination of menstruation (Casper, 2017; Erbil, 2017; Pearce et al., 2014). The symptoms of perimenopause and menopause are quite well-known: irregular menstrual cycles, hot flashes, night sweats, trouble sleeping, anxiety, etc. (Bromberger et al., 2001; Casper, 2017; Erbil, 2017). Notwithstanding vasomotor symptoms, menopause also triggers genital clinical symptoms that cannot be ignored, but are not as widely discussed (Parish et al., 2013).
During perimenopause and menopause, estrogen levels drop, which, in turn, causes a drop in the level of collagen, making the skin thinner and more relaxed (Barassan et al., 2008; Lewis, 2015; Parish et al., 2013). On the vaginal level, the epithelium atrophies, the folds of the mucous membrane flatten and thin out, the vaginal canal shortens, and its elasticity and secretions during intercourse decrease (Farrell, 2017; Rousseau, 2017). As for the vulva, the subcutaneous fatty tissues, the thickness of the epidermis, the width of the labia minora, and the size of the labia majora all decrease (Basaran et al., 2008; Bramwell and Morland, 2009; Farrell, 2017; Lewis, 2015). A 2003 study using MRI technology found that the vestibular bulbs, the width of the vagina and the thickness of the vaginal walls all diminished in size after menopause (Suh et al., 2003). These clinical symptoms, called “urogenital atrophy” or “vulvovaginal atrophy,” can sometimes appear as early as during perimenopause and can lead to a variety of other uncomfortable symptoms, such as vaginal dryness, irritation, burning sensations, dyspareunia, postcoital bleeding, incontinence, cystitis, dysuria, abnormal vaginal discharge, and distinctive odours (Erekson et al., 2016; Farrell, 2017; Huang et al., 2010; Hutchinson-Colas and Segal, 2015; Lewis, 2015; Moyal-Barracco et al., 2010; NAMS, 2015; Nappi and Kokot-Kierepa, 2012; Parish et al., 2013; Rousseau, 2017). Urogenital or vulvovaginal atrophy, which was recently renamed genitourinary syndrome of menopause (or GSM) (Portman and Gass, 2014), tends to get worse over time, as opposed to vasomotor symptoms (Erekson et al., 2016; Farrell, 2017; Rousseau, 2017; Wurz et al., 2014). These issues are sometimes accompanied by more serious pelvic problems such as genital prolapse, intestinal issues like fecal incontinence (Erekson et al., 2016; NAMS, 2015), or considerable vulval dermatoses (Lewis, 2015). However, it is worthwhile to note that a study by Huang and colleagues (2010) concluded that in 50% of cases, even without treatment, these symptoms can improve over time.
Eighty percent of women experience symptoms related to menopause, and over 50% experience vulvovaginal symptoms postmenopause (Erekson et al., 2016; NAMS, 2015; Parish et al., 2013; Rousseau, 2017). The consequences of these clinical symptoms are significant: 60% of women report a profound effect on their sex life and their emotional health (Erekson et al., 2016; NAMS, 2015; Parish et al., 2013). A study on the vaginal health which surveyed over 1,500 women found that 62% of those experiencing discomfort of some kind (dryness, pain, etc.) described their symptoms as moderate or severe (Nappi and Kokot-Kierepa, 2012). These results have been corroborated by many other studies (Huang et al., 2010; Parish et al., 2013). Unfortunately, more than 30% of women do not have access to, or do not use gynaecological services that could offer them various treatments for their symptoms, and 80% of women do not receive appropriate treatment (NAMS, 2015). This being said, although there is not much data available on the subject, many women also turn to professionals other than doctors for alternative treatments, which are oftentimes less pharma-centric and sometimes more holistic—integrating the physical, psychological, emotional, and social aspects of menopause.
Menopause comes with its share of problems. Along with physical symptoms, it is often a cause for distress among post- and peri-menopausal women (Bromberger et al., 2001; Erekson et al., 2016), which can often greatly affect their quality of life (Erekson et al., 2016; Hutchinson-Colas and Segal, 2015; Nosek et al., 2012; Parish et al., 2013). Generally, this distress is broken down into three parts: distress caused by anxiety, irritability, fear, and depression brought on by changes in the neuroendocrine system; distress caused by psychological states that are the result of emotional responses to certain events, such as menopause and aging; and distress in the face of the symptoms themselves (vulvovaginal or other) (Nosek et al., 2012). The North American Menopause Society (2015) estimates that the vulvovaginal symptoms of menopause have a significant impact on the lifestyle of 33% of women, the emotional health of 40%, and the sex life of 76% of post- and peri-menopausal sexually active women (Erekson et al., 2016; NAMS, 2015). These symptoms could also impact their love or marital life (13%), since nearly 61% of women allegedly hide their discomfort or pain from their sexual partners (Parish et al., 2013).
A recent study has concluded that over 50% of women have a negative perception of menopause, due, in part, to the impact it has on their lives and sexual activity (Erbil, 2017; Erekson et al., 2016).
According to recent studies, the vulvovaginal symptoms of menopause, namely vaginal dryness, could have an effect on post- and peri-menopausal women’s self-esteem and even on body image, for those who have a negative perception of menopause. Many other factors (in the case of women having undergone surgical rather than natural menopause, for example) must also be taken into account (Erbil, 2017; Liechty and Yarnal, 2010; Parish et al., 2013; Pearce et al., 2014).
We Don’t Talk About It Enough
A couple of years ago, I completed an observation period in gynaecology and family medicine. I saw women in tears in their doctor’s office, trying to explain the distress they felt as a result of the physical changes they experienced but did not understand, or know how to face. I realized that many of the changes that occur during menopause are never discussed, and that when they are, it is only once menopause is well underway, which can make certain patients uneasy.
According to the literature, women are not very well-versed in vulvovaginal health. This is even more true of menopause, and many experts denounce this flagrant “lack of understanding” (Nappi and Kokot-Kierepa, 2012; Parish et al., 2013).
Many women believe that the unpleasant symptoms associated with GSM are unavoidable, so they generally do not seek to solve the issues affecting their quality of life and sex life (Erekson et al., 2016; Montemurro and Gillen, 2013; Nappi et al., 2013; Parish et al., 2013). For this reason, the North American Menopause Society (2015), with the support of many researchers (Erbil, 2017; Farrell, 2017; Parish et al., 2013), is urging healthcare professionals to further educate themselves on these clinical symptoms through more communication with their patients, and by encouraging women to speak to their doctors, since many possible treatments that could alleviate some of the symptoms of menopause are available and effective. Several of these products (creams, rings, pills, gels, lubricants, etc.)—hormonal or not—can greatly help relieve these symptoms (Farrell, 2017; Hutchinson-Colas and Segal, 2015; Palacios et al., 2015; Parish et al., 2013; Rousseau, 2017). Nevertheless, hormonal treatments tend to worry patients as well as health professionals, particularly because estrogen-based products can be prescribed only with a high degree of caution (NAMS, 2015; Nosek et al., 2012). In fact, the use of these treatments is still being debated in the scientific community today. In spite of this, many health professionals have concluded that products containing only a low dose of estrogen do not pose a significant risk (Huang et al., 2010; Martin and Barbieri, 2017; NAMS, 2015; Parish et al., 2013) and that the risk-to-benefit ratio of hormonal treatments is sufficient to conclude that hormonal therapy, except in the case of women with a particular medical profile, could be much more beneficial than harmful or dangerous (Martin and Barbieri, 2017; NAMS, 2018). This being said, it is still recommended that these patients be monitored closely, as some medications with a high dose of estrogen have been linked with a higher risk of breast cancer, stroke, and heart disease (Wurz et al., 2014).
Other alternative treatment methods are also becoming more widely available, for example laser therapy, which is used for the regeneration of tissues and to restore their normal function (Hutchinson-Colas and Segal, 2015). It has proven to be effective at improving postmenopausal women’s vaginal health by alleviating certain symptoms such as dryness, dyspareunia, and dysuria (Salvatore et al., 2014).
It is relatively common for women to feel dissatisfied with some part of their physique. This rings even more true in relation to the appearance of their genitals (Bramwell and Morland, 2009), and this dissatisfaction or embarrassment can often stand in the way of women’s pleasure during sexual intercourse (Bramwell and Morland, 2009). Many teams of researchers have found, however, that dissatisfaction was not as strong in older women as in younger ones (Bramwell and Morland, 2009; Montemurro and Gillen, 2013; Yurteri-Kaplan et al., 2012). There are many possible explanations for this fact: the physical changes that come with age; the development of a strong sense of self-esteem, which may take the appearance of the genitals less into account; or simply the cohort effect, which has worked to ensure a more diverse representation of female genitals in the media (Bramwell and Morland, 2009). Hence, we can agree that, if menopausal women are dissatisfied with their genitals, it is more often not because of their appearance, but rather because of their function.
Nevertheless, the plastic and cosmetic surgery industry has offered its “solution” to the physical changes brought on by the arrival of menopause. This lucrative industry often negatively frames the vulvovaginal changes due to aging or childbirth (Bramwell and Morland, 2009). But even if more and more menopausal women are interested in this type of surgery, we must remain cautious, as no data exists on the long-term effects of these procedures on menopausal patients in terms of scarring, nerve damage, etc. (Iglesias, 2014).
Few studies have been carried out to establish what is “normal” as far as the genital anatomy of menopausal women is concerned (Basaran et al., 2008). Without imposing a standard, Barasan and colleagues argue that certain anatomical references would be very helpful in order to objectively study the results of treatments for “atrophic changes” offered to post- and peri-menopausal women (Basaran et al., 2008).
Sexual drive in menopausal women often decreases due to, for example, lower levels of testosterone (Avis et al., 2009), but also because of the repercussions on libido of the pain caused by various vulvovaginal symptoms (Parish et al., 2013). Even so, menopausal women are still very active sexually—in fact, more than ever before. The sexual activity of women aged between 50 and 69 has gone up approximately 40% since 1992 (Moyal-Barracco et al., 2010; Rousseau, 2017).
What is more, life expectancy is still increasing, while the average age at which women experience menopause in North America remains 50,5, meaning that a woman spends almost 40% of her life post-menopause (Hutchinson-Colas and Segal, 2015; Moyal-Barracco et al., 2010; Parish et al., 2013).
Thus, it is becoming increasingly obvious that we should look into the sexual satisfaction of post- and peri-menopausal women. A study has shown that 57% of women that are unhappy with their current sexual activity would like to be more sexually active (Grass et al., 2011), but feel they are held back by vaginal and urogenital atrophy-related (GSM) symptoms (Parish et al., 2013).
As of such, as many as 80% of postmenopausal women decide to continue having sexual relations despite the physical discomfort they feel, choosing instead to “tolerate” the pain and learn to live with it (Parish et al., 2013).
All articles that discuss the vulvovaginal changes associated with menopause inevitably mention how difficult is can be for post- and peri-menopausal women to maintain a satisfying sex life. We can thus conclude that this very prevalent issue should be given particular attention by healthcare professionals in order to help women suffering from GSM.
As a whole, this article offers a perspective in the heated debate on menopause. It is not my intention to write a text that could be called “penetration-centric.” However, the fact of the matter remains that these are issues deserving our attention. A strictly biological approach to menopause is not sufficient to account for all the nuances of the problems and challenges it presents, but it is an essential part of the discussion, which is why I have chosen to write an entire text on the physiological problems brought on by menopause. Leaving out sexual re-education and the opening of the conversations surrounding sex was a conscious and intended part of the writing process, allowing me to discuss a more complex perspective of the biological aspects of menopause. This being said, this article is one of many ventures into the vast universe of menopause.
In conclusion, although a large majority of women experience many vulvovaginal symptoms of menopause that can lead to psychological distress, there are many ways to mitigate these issues. There are medical treatments available for these physical symptoms (Palacios et al., 2015; Rousseau, 2017), but a shift in our perception of menopause could also greatly help women navigate this period of change (Erbil, 2017).
All things considered, in order to facilitate a realistic perception of menopause, we need to adopt a positive attitude towards it and adequately educate women about this phenomenon throughout their entire lives. It has already been proven that women with a positive outlook on menopause before and during perimenopause tend to have a better perception of themselves and experience less psychological distress throughout the process (Erbil, 2017). Better and more information on the expected changes would also likely help prepare women for menopause. In short, let us lavish the long-lived vulva.
O, revered vulva
O, light, laudable labia
May you be loved and lavished
Even through your menopausal anguish
Though you may transform
Never will you be forlorn
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