What happens to your sex life during perimenopause?
For some women, perimenopause can accompany a drop in libido and changes to the body that impact sex. (ABC: Anna Levy)
When Ange met her boyfriend three years ago, it was the start of what she describes as the best sex of her life.
During the 15 years she was married to her ex-husband, she felt that her erotic life had left a lot to be desired.
At 42, this was the first time she was able to have an orgasm from partnered sex.
"Suddenly I was having this just incredible, mind-blowing sex," she says.
"I started having an orgasm, I was literally baffled for a second and then I went, 'Oh my God, I'm having an orgasm' … It was that surprising to me.
"I actually phoned my friend afterwards and I went, 'What is happening?'"
Starting a new relationship with her partner felt like a reward for the long years of dissatisfying sex.
But then Ange's body turned against her, and she experienced pain during sex for the first time.
"It's like my vagina just refuses to cooperate," she says.
"I used to have no trouble with lubrication, but now it's just not working. It's sort of dry, it's painful, even with lube it can be painful, and it's just really hard because that's one of the ways that I show my partner how much I love him.
Perimenopause can last for up to 10 years and is characterised by fluctuating hormones and, at times, a disrupted sex life. (ABC: Anna Levy)
"It's really frustrating because I've waited so long to have a relationship like this [and] the sex is such a huge part of it."
After some investigating, Ange discovered she was in perimenopause, which is the time leading up to the end of a person's reproductive stage. It can last for up to 10 years and is characterised by hormones fluctuating and, for some women, a disrupted sex life.
Some women have no or mild symptoms, but for others, perimenopause can accompany a fall in libido and changes to the body that impact sex.
Ange's doctor told her she had vaginal atrophy — or "genitourinary syndrome of menopause" (GSM) — which describes the changes in a woman's vulva as hormone levels decline. These include the thinning of the skin and loss of lubrication that can lead to pain.
And for Ange, the "powerful" orgasms she had with her new boyfriend have also seemingly been diminished.
"It can be absolutely heartbreaking at times," she says.
"When I found out I was in perimenopause, I was actually just furious that I'd wasted so many f**kable years on my ex-husband."
But despite the challenges that come with nearing menopause, Ange, like many other women, has learned that a robust sex life doesn't need to be discarded and forgotten as her body changes with age.
A common concern
Sheryl Kingsberg is a clinical psychologist at the Department of Reproductive Biology at Case Western University.
She says that during perimenopause, women who have never experienced pain during sex can start to have issues as the loss of oestrogen and other hormones changes the body.
Dr Kingsberg says that studies show that up to 80 per cent of women will develop GSM.
"The vagina can actually narrow [or] shorten; the tissue in the labia, so the outside of the vulva, can also shrink; the clitoris itself can shrink — and that's all because of the loss of estrogen.
"Pain is the most common [sexual problem] to really bump up against.
Studies show that up to 80 per cent of women will develop a genitourinary syndrome of menopause (GSM). (ABC: Anna Levy)
"As we age, there are changes in nerve endings and as the tissue changes, it becomes sometimes a little bit more difficult and we need more stimulation to be able to reach orgasm.
"Too many women do not know that that is a common occurrence with menopause, because they know about hot flashes, but they don't think about those changes that are chronic and progressive."
Along with hormone fluctuations that alter the body and sexual stimulation, Dr Kingsberg says the stresses and worries of midlife can cause someone's sexual appetite to diminish.
"If she is now fatigued, if she's having 10 hot flashes a day, if she has brain fog, those all can negatively impact one's sexual function," Dr Kingsberg says.
"When you settle into a long-term relationship and maybe you have children or work or essentially boredom, that's harder on a couple's sexuality. And so for some women, the longevity of the relationship can be a detriment to that drive."
Getting help
Part of the challenge for some women is that getting help for their perimenopausal symptoms can be complicated and difficult.
For instance, it took Ange a lot of trial and error to find a physician who would talk about the problem with her.
"It's been like unpacking a puzzle," she says.
"When I got a new doctor, she was great and she was able to tell me that, yes, this atrophy was happening. It was very much about treating the symptom, but not about what I could expect in my sex life.
"You need to take ownership of what's happening for you. And if you don't get the answers that you feel are right … just keep pushing until you do feel that you've got what you need."
For some women, deciphering and getting help for their perimenopause symptoms can feel like "unpacking a puzzle". (ABC: Anna Levy)
Professor Kingsberg says part of the issue is some medical experts can be just like their patients: shy to talk about sex and relationships.
For women feeling awkward about a GP visit, she suggests writing down their questions and bringing them to the appointment
"I spend a lot of my career trying to teach physicians and nurse practitioners how to be comfortable addressing sexual concerns in their patients, because if they look embarrassed by it, then their patients are going to say, 'Well, clearly I can't talk to this clinician about my sexual concerns'."
For those who do feel comfortable talking to their GP, Dr Kingsberg says there are many medical options for people experiencing pain and discomfort associated with GSM. These include hormone treatments applied directly to the vagina, suppositories, rings and gel caps. And for women who don't want to put anything inside their vagina, there are oral pills.
"You can use a moisturiser just like we would use creams to moisturise our face. There are moisturisers developed for the vulva and vagina," Professor Kingsberg says.
"But to restore the tissue, you really need to think about hormone therapy [specifically] for the vagina and the vulva."
And she says there are practical considerations to make in the bedroom, too.
"[Some women] may need to shift how they achieve orgasm. As women age, the vibratory nerves are the last to go, and so for women who could easily achieve orgasm in their younger years with manual stimulation or oral sex or penetrative sex, they may notice as they age that they need more direct and more vibratory stimulation.
"So oral sex and vibrators are often very helpful. There are thousands of [vibrators] — it is a multi-million-dollar industry for good reason."
Professor Kingsberg says that it's important not to lose sight of what can be a healthy future — it may be one where sex will change, but is still a source of great joy and a central part of our lives.
"Sex as you age can be amazing. You know your body better, you're no longer chasing after some youthful image of what should be, and you can settle into what you want to be," she says.
"I think that women should be given a different message, that sexuality as they age may require change, but change absolutely can be better."
Keeping the mood light
About three years into their relationship, and after finding the right GP, Ange started treatment to help with her pain during sex. She relies on the intravaginal hormone cream, which she has to apply at night.
Ange, like many other women, learned that she could still have a robust sex life once she got help for her perimenopause symptoms. (ABC: Anna Levy)
"I do have to remember to do that, and my memory's a bit s**t because I have perimenopause, so I put [a reminder] in my phone," she says.
"The first time I started taking it, within about a week and a half, it felt like I was back to the level from before. It's a lot more lubricated and that was awesome.
"Sometimes we'll use a toy and that does help to get the blood flowing. And then after that, it's amazing and it's like what it was [before]."
Ange takes a novel approach when talking to her partner about what's going on with her body. This playfulness helps her share what's going on.
"I invented a character for my vagina just to keep the mood light," she says.
"I refer to her as a 'she' and that allows me to be playful, which makes it more comfortable for me. [It's] a bit silly, but it works.
"[Sometimes] I just go to him, 'Oh, she's not cooperating this morning' and so that allows me to kind of reduce the awkwardness that I feel. I would rather be slightly embarrassed for 10 seconds telling him what's going on than ever have him feel that I don't want him — because I desperately want him.
"It's amazing that we can communicate in the way that we do, and we also laugh a lot in bed, which is great. And we're [still] kind of jumping each other all the time, so we really are still horny for each other."