Demystifying Sexual Health In Midlife

Sex and your sexuality. Maybe you think about it, maybe you don’t. But if you are in perimenopause or menopause, most likely how you think about it has shifted due to changes in your hormones and your body. I know it has for me. But getting evidence-based information or help to navigate these changes is hard (and it shouldn’t be!).

It is hard because there is still a taboo against talking about women’s sexuality and unfortunately our primary care doctors and OBGYN’s are not traditionally trained in menopause or women’s sexuality. Having said that, experts do exist, and telehealth is changing our ability to access some of this help. 

I was thrilled to recently connect with Jackie Giannelli, founding nurse practitioner at Elektra Health, and women’s sexual health expert for an in-depth conversation about women’s sexual health. Elektra Health is a female-founded company empowering those navigating menopause with research-backed expertise, personalized coaching, and community. Holos is thrilled to partner with Elektra to offer a special discount to their community. You can use the code “HOLOS25” to receive 25% off an annual membership.  You can sign up here.

I only wish every woman had an opportunity to work with someone like Jackie, smart, knowledgeable, and approachable. Over the course of the next 2 issues, I will share our conversation on “normal” sexuality in midlife, sexual dysfunction in perimenopause and menopause, what treatments exist, nurturing intimacy, and some of her favorite resources. 

This is one of the most important conversations I have had, and I can’t believe how much I learned! I encourage you to share this with friends and family. As I sit here at 52, I am disappointed that women don’t have better access to the support we need and deserve. It is time we demand more!

Karyn: It seems there is still a taboo in talking about women’s sexuality. What needs to happen to change this narrative? 

Jackie: Changing the taboo starts with the desire to learn and making the conversation around sexual health more comfortable to have. 

While the problem is systemic and needs a multi-modal approach, change begins with education. Only 1 in 5 OBGYNs have any training in menopause, and it is even lower for women’s sexual health (libido, arousal, orgasm, pain). As the recent piece in the New York Times said, ”Half the World Has a Clitoris. Why Don’t Doctors’ Study It?”

More training needs to happen in medical school and residency so providers can feel comfortable asking their patients about their sexual health. Many providers don’t ask questions because they don’t feel comfortable, prepared, or able to address the questions they might get, either due to a lack of time during the standard visit, lack of reimbursement, or a lack of education. This is compounded by the fact that there are not a lot of great options if a doctor needs to refer a woman out to someone. 

Changing the status quo is also about raising awareness of these issues, like what you are doing with Holos, and women demanding more resources.

Karyn: How can a woman differentiate between healthy sexuality and sexual dysfunction? 

Jackie: Sexual dysfunction is a biopsychosocial issue, not just a physical one. It is an emotional, mental, spiritual confluence in the body and the brain. 

A healthy libido after age 40 is different than in your 20s. You are not necessarily chasing spontaneous desire anymore; what is more typical is a more responsive desire to sex. By this I mean you might not necessarily have sex on the brain all the time but the barrier to entry is not high. Meaning when your partner initiates it you don’t mind. And many women find once they get started, they can get into it. 

I get asked a lot about low libido. Aside from pain, which everyone would agree is not acceptable, low libido is not necessarily sexual dysfunction. If someone’s perspective is “I don’t want to have sex and I don’t care”, that is not sexual dysfunction from a medical perspective. Although it might still be a source of tension in a relationship. 

However, loss of libido which is distressing is known as Hypoactive Sexual Desire Disorder (HSDD). This is a clinical diagnosis for which there are different types of treatments. Figuring out the right treatment is a process of trial and error. There are currently 2 FDA approved drugs on the market for treating low libido, Addyi and Vyleesi. While technically approved only for pre-menopausal women (as that is where the studies where done), they are often used off label and can work for some post-menopausal women. 

Ultimately, the most important part of treating low libido is understanding what is going on in my patients’ lives. I work to understand what is happening to their bodies, with their emotions, and their motivations. 

For example, someone might say, “I just lost my desire for sex. I used to love it and think about it all the time and then menopause came, and now I would rather lick the carpet than have sex!” I might then ask follow-up questions, such as “Are you having any pain when you have sex? This is important because if something is the least bit uncomfortable, your body will subconsciously resist it. In this case, we try to figure out what is causing the pain, for example vaginal dryness or bladder problems, and address it. 

Or, I might say, “OK, you don’t want to have sex. Is that because you are not having any pleasure when you do have sex?” Or maybe someone is having trouble getting aroused or having sexual thoughts. 

What I love about the practice I also work with in New York, Maze Sexual & Reproductive Health, is we integrate therapists into our treatment plans. I can give someone testosterone replacement therapy or Addyi for example, but we might also need to reframe your narrative around sex and desire. 

Our therapists say you do not technically need desire to have great sex. What you do need is arousal. For women the equation is arousal followed by desire, whereas for men, it is the opposite. Women tend to need to think a little more about the motivation or the goal. Is the reason to have sex to feel closeness with your partner? Is it because you are stressed, and an orgasm would be an awesome stress relief? 

Dealing with issues of arousal also requires tapping into your erotic roadmap, essentially what turns you on. This already exists in your brain and was built when you were younger. For someone who has experienced strong feelings of desire in the past, you know what turns you on and it is about re-accessing this as your brain is your biggest sex organ.

I also review medications people are taking which might impact libido, like SSRI’s. Research has demonstrated that up to one-third of women in perimenopause experience depression, and a lot are on medication. If this is the case with one of my patients, I work with them to find medications for their mood which have less negative sexual side effects. 

We are still learning about the interplay of hormones in the brain. And sometimes working to balance hormones during perimenopause can do wonders for a woman’s mental health, and thus her sexual health. They go hand in hand. 

As a clinician focused on the medical aspect of treatment, I want to get my patients in a physiologically happy place. Sometimes it is as simple as giving back neuromodulators in the brain through medications like Addyi or hormones with HRT. This helps patients get into a good place to do the behavioral work with a therapist and really sink their teeth into it. Otherwise, it would be like throwing something against the wall and nothing would stick.

However, despite all these options if you are a perimenopausal woman who is not sleeping, having hot flashes, anxious all the time, dealing with aging parents, and working…then asking yourself to get in the mood is a Herculean effort! It is important to understand where you are and the reality in which you are living. 

My work with my patients is a partnership and requires honest conversations. It also means trying different solutions and sticking with approaches which seem to work as there are no overnight fixes. Often the brain needs time to rewire the neural connections and that can take months or years. 

Parting Thought

I loved this interview because it gave me hope. While menopause is inevitable, the changes it brings don’t need to cause shame, embarrassment, or frustration. Spreading this message is part of demanding the care and support we deserve!

Jacqueline Giannelli, MSN, RN, FNP-BC, NCMP is a member of Elektra’s founding clinical team. She is a board-certified family nurse practitioner specializing in women’s health with a special focus in menopause, urogynecology, and sexual health. Jacqueline is a North American Menopause Society-certified practitioner and Assistant Medical Director at Maze Women’s Sexual Health in New York. You can find her at @jgramseyer7 and on LinkedIn.

To be continued…