Making Sense of Menopause

Making Sense of Menopause

Making Sense of Menopause

A Biopsychosocial approach to thriving (not just surviving) during the transition and beyond. (I once had a patient say to me that menopause = Men on Pause, as that was how she was feeling in her body). But this blog is all about YOU and helping to be comfortable in your own body.

Hot Flashes, Night Sweats, Joint pain, Muscle loss, Bone density loss, Vaginal Dryness, Pain or Altered Sexual Activity, Bladder and/or Bowel Control Issues.

These are all conditions that commonly occur in women during perimenopause and menopause due to declining estrogen levels.

Menopause occurs naturally in every woman; the average age is 51 years (one year of no periods). Hormonal fluctuations often start in the 10 years or so before that. This is called perimenopause. 

Cancer treatments can lead to an abrupt drop in Estrogen that has been referred to as “Menopause on Steroids”, due to a sudden, vs gradual, onset of menopausal symptoms.

In this Four-Part Blog we will discuss: 

  1. Sexual Health

  2. Managing hot flashes and night sweats

  3. Bladder and bowel health

  4. Bone and muscle health

Part 1. Sexual Health with special attention to after a breast cancer diagnosis

GSM: Genitourinary Syndrome of Menopause: A collection of symptoms and signs associated with decreased estrogen and other sex steroid levels that can involve changes to the labia, clitoris, vagina, urethra, and bladder. 

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Signs and Symptoms of low/no estrogen:

  • Dryness / insufficient moistness in the vulva and vagina

  • Dyspareunia (pain with vaginal penetration)

  • Itching, burning, soreness in and around the vagina.

  • Tightness/ loss of elasticity

  • Thinning of the vaginal tissues

  • Deficits in the mucosal layer – petechiae (little red spots), tiny fissures, ulceration, inflammation

  • Shortening of the vagina, narrowing of the introitus (entrance to the vagina)

  • Decreased blood flow.

  • Smoothing of the vaginal rugae (see image above) – less surface area = less stretchy and resilient.

  • Recurrent UTIs (in part due to decrease in vaginal pH letting the “bad” organisms have access to the urethra.   Estrogen is like a probiotic for your vagina – helps the pH to stay low = more acidic. 

  • Urinary urgency, frequency, urinary incontinence.

Treatment:

  • Overwhelming data shows that local vaginal estrogen will prevent recurrent UTIs in peri and post-menopausal women and it’s recommended by the American Urological Association (AUA) in their guidelines on recurrent UTI. 

  • Not only will vaginal estrogen decrease recurrent UTIs, but it will improve many lower urinary tract symptoms including frequency, urgency, and painful urination. It will also help improve arousal, lubrication and decrease painful penetration. 

  • Consider talking to your doctor about vaginal estrogen cream. 

Special Considerations with Cancer Treatment:

  • For patient’s taking aromatase inhibitors due to Estrogen-Receptor Positive Breast Cancer (meaning that estrogen feeds the cancer; not that it caused the cancer).

  • For patients who for ANY reason are not considered good candidates for local estrogen therapy. Bottom line is it is always a conversation with your oncologist. This is a quality-of-life issue, and it is important to get the most pertinent information for your specific situation. 

  • Non-hormonal Vaginal Topical Options:

    • Vaginal moisturizers such as Reveree by HelloBonifide.com, Solfwellness.com, Bionourish by Good Clean Love.  Hyaluronic acid is a good ingredient to look for. 

    • Hyaluronic acid helps with vaginal dryness and pain but will not likely help with bladder concerns.

  • You can also talk with your doctor about DHEA (precursor to estrogen) and Imvexxi (a very low dose Estrogen)

Vaginal Lubricants: to use during sexual activity, or with a vibrator or dilator / toys:

  • Water based: close to your natural lubrication but doesn’t last very long. Safe to use with vibrators, dilators, condoms. May need to reapply often.

  • Oil based: longer lasting but not as much glide, interferes with condom integrity.

  • Silicone based: Longer lasting, good glide but cannot use with silicone vibrators / sex toys.

  • Stay away from: glycols, glycerin, parabens, dyes, perfumes, flavored, warming / cooling, glitter / gold flakes (as fun as those might sound). 

  • Choose a pH balanced lubricant: to avoid upsetting the delicate vaginal flora. Vaginal pH is between 3.8 and 4.5; to avoid increased risk for infection.

  • Don’t use household products: coconut oil (emerging evidence that it can change the pH of the vaginal microbiome), Vaseline, olive oil, baby oil, hand cream. 

  • Some product suggestions: from YES, Good Clean Love, Intimate Rose, Desert Harvest. 

What about Pelvic Floor Physical Therapy?

  • Pelvic floor muscle training over a 12-week period shows significant decreases in vaginal dryness, improved blood flow, improved ability to relax the muscles, increased quality of life, decreased urinary incontinence. 

  • It is important to have a pelvic floor assessment by a skilled pelvic floor PT before you start on a muscle training program. Learning about the anatomy and function of the muscles and supporting structures helps you to understand what is going on down there.

  • Learning to coordinate your breathing with your pelvic floor helps your brain to reconnect with this part of your body again. This mind-body connection enables you to have a better sense of when you are holding your muscles tight vs when you can let go and release tension. 

  • If appropriate and tolerated, internal vaginal myofascial mobilization techniques are used; but you will also learn strategies you can do at home, such as breathing and appropriate stretches. 

  • Using vibrators! for easing vaginal tightness, as an alternative to vaginal dilators, for scar massage, to promote blood flow, lubrication and orgasm. Vibrators can be a first step back to enjoying sex… without the pressure of a partner. Vaginal vibrators help to improve pelvic floor muscle strength as well as to modulate pain.

  • Vaginal dilators, biofeedback, vaginal wands and vibrating wands – there are tools available to help with home management programs.

Exercise: already known to have significant benefits to health and well-being; also has the potential to enhance women’s sexual lives as well. The basics: 20-minute daily walk; resistance training 2X/week. But also yoga, running, hiking have all been shown to improve orgasm.

  • Exercise is guaranteed to be a key part in every intervention to help live well during and after cancer.

Potential Psychosocial Limiting Factors: 

  • The Brain is our #1 sexual organ.  If women are exhausted due to chemo-induced fatigue it is difficult to prioritize sex. Consider taking mid-day rests; avoid large meals, alcohol before sex.  Consider positioning with more supports that requires less exertion.  If pain, nausea, diarrhea are problems – consider medications to address these issues. 

  • Body Image: Hair loss, weight loss / weight gain. Changes in, loss of sensation in breasts/ nipples; appearance and feeling of scars.

  • Finding new ways to connect with your body through mindfulness, meditation, working with a psychotherapist are all potential ways to start that process.

Resources: 

  • Sex and Cancer Intimacy, Romance, And Love After Diagnosis and Treatment by Saketh R. Guntupalli and Maryann Karinch

  • The Better Sex through Mindfulness Workbook by Lori Brotto PhD.

  • Come as You Are by Emily Nagoski 

  • You Are Not Broken- Stop “Should-ing” all over your Sex Life by Kelly Casperson, MD

  • Vibrators 

    • Lelo.com (gigi2) – use code CELEBRATE

    • Intimina Vibrators (Raya Quiet, or Celesse Personal) – available on Amazon

 

Next up: Part 2- Managing Hot Flashes and Night Sweats