Content written by Irwin Goldstein, MD

Menopause is a natural biological process that consists of physical and psychosocial changes. Peri-menopause, when a woman still has her period, is the time when she may begin to experience menopausal signs and symptoms even though she is still ovulating. Menopause is considered to be the 12 months after a woman’s last period. The years that follow are called post-menopause.

Menopause begins naturally when ovaries begin to make less estrogen and less progesterone. At menopause the ovaries cease estradiol synthesis, but may continue to make androgens during post-menopause. Menopause is usually a natural process, however certain treatments can initiate it. An operation that removes both uterus and ovaries causes “surgical menopause.” With surgical menopause, there is no peri-menopausal phase. Chemotherapy and radiation therapy can also induce menopause. Premature ovarian failure is a rare cause of menopause, and may result from genetic factors or auto-immune disease.

Menopausal symptoms are different for each individual, but among the most common symptoms are diminished sexual interest, diminished sexual arousal including vaginal dryness, thinning of the vaginal wall, diminished lubrication, diminished intensity of orgasm, and dyspareunia or painful intercourse. During peri- and post-menopause, compared to pre-menopause, sexual health problems occur more frequently, are more often irreversible, and are more likely to be progressive, particularly if the cause is associated with vaginal atrophy secondary to estrogen deficiency. In some menopausal women estradiol can still be naturally synthesized, but thie does not occur in the ovary but through conversion of androgens to estrogens in the adrenal gland or in the periphery such as fat tissue. If the estradiol values are adequate, some women may not experience many symptoms of menopause.

Diminished estrogen production may render genital tissues susceptible to atrophy within weeks to months. The pH becomes neutral or alkaline increasing the likelihood of vaginal discharge and odor. Atrophy of the vagina may cause it to become pale or colorless, lose its ability to easily stretch and widen during sexual arousal, and cause diminished blood flow, resulting in decreased lubrication and vaginal dryness. Thinning of the vaginal lining layer may cause it to bleed. When intercourse is attempted under conditions of low estradiol, sexual activity can be painful, unpleasant, and unsatisfactory. Estrogen deficiency may result in reduced genital sensation. The clitoral hood may become scarred and the glans clitoris may atrophy. There may be thinning of the hair of the mons and atrophy and shrinkage of the labia minora and labia majora with decreased subcutaneous fat and skin elasticity. Low estradiol may prolong the time to achieving genital arousal and reduce the intensity and number of vaginal and uterine contractions during orgasm.

Androgens are also critical in maintaining genital tissue structure and function in menopausal women. Androgens also improve desire and orgasm responses, bone and skeletal muscle metabolism, cognition, feelings of wellbeing, and mood. It is important to measure and, where appropriate, manage both estrogen and androgen hormones in the post-menopause. Low estradiol and androgen levels may adversely affect sexual health resulting in a vicious cycle of avoidance, performance anxiety, and decreased sexual desire.