Hi Beautiful Friends,
Most women are unfamiliar with their genital anatomy. A recent poll showed that when shown an image of pelvic anatomy, one in four women misidentified the vagina and 46% could not identify the cervix.
Knowing Your Anatomy
Maybe it’s time to take a closer look. Hold onto your pants. This could be a shocker.
Did you know…
The clitoris isn’t just a nubbin on the outside at the front (the glans) but also includes two internal arms (the crus, which is Latin for “leg”) spanning up to 5 inches on either side of the vestibule. The crus contain the same erectile tissue found in the penis, which means women are capable of several more inches of erection than most men. Just sayin’.
See for yourself!
GSM (Genitourinary Symptoms of Menopause)
The decline in estrogen during perimenopause leads to reduction of blood flow to the genitalia, lower production of lubrication, shrinking of the clitoris, and thinning of the vaginal wall, all of which make it more difficult to orgasm.
These changes plus symptoms of itching, dryness, and loss of elasticity in pelvic floor tissue are signs of GSM (Genitourinary Symptoms of Menopause). Just saying it shrinks my libido. Not sure what’s worse: the symptoms, the cumbersome name, or the fact that in a recent, large study of women six years after their final menstrual period, up to 84% were suffering from GSM.
GSM is chronic and progressive, and can lead to pain during sex, incontinence, and urinary tract infections.
GSM is under-diagnosed and under-treated because women
don’t seek help at the onset of symptoms
avoid medical consultation and end up treating on their own using sub-optimal solutions that don’t address root cause
don’t seek treatment because they believe the changes and symptoms are just a matter of getting older
The Safe Solution
Localized vaginal estrogen therapy when applied early can prevent GSM from developing. If the treatment is begun after menopause, it may reverse some of the vulvo-vaginal atrophy and reduce dryness and other bothersome symptoms.
Vaginal estrogen in the form of rings, creams, or tablets, does not affect systemic levels of estrogen and is safe to use throughout a woman's life no matter what age, even if she has a history of cancer or clots.
Testosterone For Low Libido
Testosterone levels in women are higher than estrogen levels in premenopausal women. Decline in testosterone can cause lower energy levels, difficult maintaining muscle mass, and loss of libido.
The sexual health of men is acknowledged as an important component to their quality of life reflected in the well-tested and approved medicines that are easily accessible to them.
In a recent, Hit Play not Pause podcast episode with menopause expert Dr. Susan Davis, she speaks extensively about testosterone treatment which she has been prescribing since the 1980’s.
Local NAMS-Certified OB/GYN: Dr. Prabakar
"Women who experience low libido now have options!" says one of the few NAMS-certified OB-GYN's in the bay area. Dr. Cheruba Prabakar says "In addition to menopause hormone therapy, there is good evidence for the safe use of testosterone for low libido."
Importance of Sexual Health
Dr. Pebble M. Kranz recently wrote an article lamenting our tendency to underestimate the importance of sexual activity in women. She recognizes that sexual physiology and behavior change with age but that sexual health remains an important factor in the general well-being and overall health of older women. She says, "Given the high prevalence of dementia among this population, it may be useful to know that positive sexual expression may delay cognitive decline. We also have evidence that sexual satisfaction is important for relational health, which in turn helps predict physical health."
Low libido is bio-psycho-social, meaning it is multi-faceted. The decline in sex hormones during perimenopause and menopause is the bio factor, which can be aided by hormone therapy. Some other suggestions include:
More mental and physical stimulation may be necessary. As hormones decline, so do nerve endings, but the ones that are sensitive to vibration appear to be the ones with the most longevity. Sexual health doctor Lauren Streicher MD refers to the vibrator not as a "toy" but as a "tool" we should keep on hand in the bedroom.
Spend more time planning and scheduling as well as warming up. In her best-selling book Come As You Are, sex researcher and educator Emily Nagoski discusses how as we age we respond differently to types of arousal, and spontaneous arousal (hot to go at the drop of a hat) is often replaced by responsive arousal (I’d rather clean my andirons, but…if we take some time to warm up, I’ll probably come out happy in the end).
Be aware that other medications such as oral contraceptives and anti-depressants often contribute to diminished libido.
Surgical and procedural changes to anatomy also affect sexual function.
Now let me introduce you to a few more knowledgeable, outspoken allies who are experts on GSM and pelvic and vaginal health.
Local Pelvic Floor Physical Therapist: Dr. Upke-Wallace
Dr. Aniete Upke-Wallace is an Oakland local pelvic floor therapist. She provided me with the detailed image above and teaches women how to build healthier relationships with their sexual body parts. Check out her informative substack, Tending to Your Womb.
Urologist and Advocate: Dr. Rachel Rubin
Dr. Rachel Rubin is a urologist who has marched on Washington for improvement in menopausal care and research. She says that every woman at age 45 should go to her doctor for a lifetime prescription of vaginal estrogen cream. Listen this webinar where she covers a wealth of information on vaginal health.
Sex Expert and OB/GYN: Dr. Lauren Streicher
Dr. Lauren Streicher’s webinar for the national non-profit Let’s Talk Menopause covers pretty much everything on midlife sexual health. She’s written several books and has her own podcast as well.
In Solidarity
Here is an additional list of resources if you'd like to learn more:
Dr. Streicher's Inside Information: THE Menopause Podcast, Episode S1. Ep.3: What's Up Down There? Genital Dryness and Misbehaving Bladders
Slip, Sliding Away: Turning Back the Clock on Your Vagina by Dr. Laura Streicher
Perimenopause WTF? Podcast: Your Vagina & Perimenopause with Dr. Alyssa Dweck
NAMS Position Statement: https://www.menopause.org/docs/default-source/default-document-library/2020-gsm-ps.pdf