Part 2: Sexual Health In Midlife

Welcome back to Part 2 of my conversation (click here for Part 1) with Jackie Giannelli, NP and women’s sexual health expert. Jackie is the founding nurse practitioner at Elektra Health and a women’s sexual health expert. 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. You can use the code “HOLOS25” to receive 25% off an annual membership.  Link to sign up here.

Last week we “right-sized” libido for women over 40 and talked about sexual health and dysfunction and discussed treatment options. Today I wrap up my conversation with Jackie, touching on low libido and vaginal pain, exploring and nurturing intimacy, and some of her favorite resources. 

Once again, I encourage you to share this information far and wide! 

Karyn: How does sexual dysfunction typically show up in perimenopause and menopause and what treatments exist? 

Jackie: There are 2 main issues which people come to me for help, loss of libido and painful sex. 

In the case of Hypoactive Sexual Desire Disorder, or loss of libido which causes distress, I usually start with testosterone replacement therapy for my perimenopausal or menopausal patients who are candidates. To be clear, we are not trying to bring women to male levels. We are replacing testosterone to a physiologically optimal and healthy level for a woman who is sexually active, exercising, wants to maintain her bone density and her muscle strength, and feel more vitality. 

When you replace a woman’s testosterone you increase the likelihood that her orgasm will be better, and it can help with arousal. I encourage women who don’t have access to a sexual medicine health provider to print off the ISSWSH testosterone treatment guidelines and bring them to her OBGYN. This will impress upon her OBGYN how serious she is about addressing this issue.

Other treatment options include Addyi and Vyleesi, which are taken daily or as needed, depending on the medication. These work by increasing certain neuromodulators in the brain which help with pleasure seeking, and by modulating others which act as inhibitors. These are not drugs for anxiety or depression and can be used in combination with other drugs like SSRIs. They can also be used in conjunction with testosterone. If someone responds well to these it can really change their world!

In terms of trying direct-to-consumer supplements, there is often little harm in trying some of them, although it's super important that you seek out high quality brands that are vetted for safety. I would also caution people to be careful of products with DHEA as this is an over-the-counter hormone and an excess of DHEA can mess with your hormones.  Ultimately, it's important to discuss any supplements you might consider taking with your healthcare provider to make sure it’s safe and won’t interact negatively with your other medications.

A couple of supplements for women’s sexual health from companies I trust are Ristela by Bonafide and LibidoStim-F by Designs for Health. If you are going to try a supplement, 3 months is the minimum amount of time I would suggest is needed to decide if it is helpful or not.

The 2nd major issue I encounter most often is pain with sex. In perimenopause and menopause this is often tied to vaginal dryness or GSM (Genitourinary Syndrome of Menopause) which encompasses vaginal dryness, loss of elasticity, narrowing of the vaginal entrance, and urinary symptoms. The good news is vulvar and vaginal pain is treatable, but unfortunately, many providers just don’t have the experience to treat this type of pain effectively. 

In terms of treatment, there is a lot of evidence that vaginal estrogen is safe for almost everyone - even safer than Tylenol! I believe it should be available over the counter as it is in Europe. You can even use it before menopause. By being proactive you help maintain the structure and function of the vagina as well as the vaginal microbiome. And those taking systemic HRT can use local vaginal estrogen as well, particularly if someone is taking a very low dose of HRT.

The vagina and vulva are also rich in androgen receptors (testosterone). I like to use vaginal DHEA as it turns into testosterone which can help with arousal and lubrication. Testosterone is an important component to address as replacing testosterone in the vagina and vulva can help improve the quality of these tissues over time.

Karyn: Do you have any tips or advice for women who may not be experiencing sexual dysfunction but would like to improve intimacy in their lives?

Jackie: Yes! Intimacy should be thought of as both intimacy with a partner and/or yourself. 

Good communication is crucial for intimacy. It is important to communicate to your partner what is happening with your body and how you are feeling. This can be hard and is a commitment, like any good wellness practice, and it is easy to slip into bad habits over time. BestSelf has a great deck of intimacy cards which I love…they are great conversation starters for women and their partners. 

For women with low desire but with partners with high desire, scheduling sex might allow them to meet in the middle. This can be a better strategy than avoiding your partner when you know they want to have sex and you don’t. Also, I don’t recommend having hard conversations around your sex life in the bedroom, find a more neutral space. 

It is also important to understand that sex and intercourse are different. You do not need penetrative sex to experience pleasure. Finding new ways to experience pleasure can help infuse your relationship with new energy. Don’t just think about sex as “getting the job done.” Take the time to explore different body parts and new sensations and see how they feel. 

Our therapists talk about practicing mindfulness around sexual activity. For women trying to access pleasure they suggest holding a raisin in your palm. Notice the crevices and shape. Then put it in your mouth and roll it around on your tongue. Notice how it feels. Take a bite. Notice the flavors and how the juice feels in your mouth. 

This exercise is about slowing down, taking your time, and noticing the little details. This is how you should be experiencing sex with yourself or your partner. It is not about having sex to have an orgasm. It is about rediscovering what works for you, what doesn’t, and then talking about it afterward with your partner. 

Karyn: Who is the right person to seek out should someone be experiencing symptoms of sexual dysfunction? 

Jackie: It is hard to find a specialist and you might have to start with your OBGYN or primary care provider. I find NPs and APRNs, because they are trained in educating and listening, to be better sounding boards and more willing to help find additional resources. 

You might also start with a therapist, particularly if you have been living with pain as that can create emotional issues. The American Association of Sexuality Educators, Counselors and Therapists (AASECT) is a good resource, and the International Society for the Study of Women’s Sexual Health’s (ISSWSH) website offers a Find a Provider function. 

Karyn: Should women be looking to work with someone who is certified in menopause?

Jackie: I would suggest seeking out a provider who's certified by the North American Menopause Society (NAMS) if possible, as only 1 in 5 OBGYN’s have received any training in medical school or residency on menopause. 

I recognize not everyone may be able to find a certified provider. And so, I am very excited about the opportunities offered by telehealth, which can help fill in the gaps of conventional medicine. At Elektra Health where I work, clients are assigned an expert guide, who is trained in health coaching and the Elektra philosophy of evidence-based care. Every client gets a personalized wellness plan, including lifestyle, behavioral, and psychosocial emotional goals. These guides can also help with specific goals like losing weight or tackling sleep issues. They are there to hold you accountable AND to be your cheerleader.

Lastly, if you are going to talk to your doctor about menopause, don’t do it during your annual exam. Make a separate appointment to talk about menopause, write down your questions in advance, and focus on your main symptoms. There are 34 possible symptoms of menopause, and it would be impossible to address all of them in one visit.

Karyn: What are some of your favorite resources for women who want to learn more about what is happening to their bodies during perimenopause and menopause?

Jackie: I would suggest Elektra Health’s 21st Century Guide to Menopause and the North American Menopause Society’s website.  

There are also some fun, cool products on the market for women who want to experiment with new ways to find pleasure. There are CBD serums, erotic podcasts (check out Dirty Diana, produced by Demi Moore), and sites like Good Reads which offers various erotic book groups (here is one). Some you will like and some you might think, “Thank you, but no!” I would just encourage people to try new things and keep an open mind!

Parting Thought

Knowledge truly is power, particularly when advocating for your own health care. I am thankful for people like Jackie who are working to destigmatize women’s sexuality and spreading the word about options for women looking to have healthy sex lives, whatever that might mean to you.

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…