There are many books (one is mine….time for that plug I’m Not in the Mood; what every women should know about improving her libido), surveys, prospective and retrospective studies, theses on how to do the studies, pharmaceutical investigations and internet come-ons suggesting that you, the adult woman should “buy this and fix your sex life”.

They have all put the fear of menopause in women….not only because this transition may cause hot flashes (and all those other symptoms I treat and yes discuss in my other books, and I won’t go into the list) but because it will cause sexual desire to go kaput!

Many of my patients want me to give them a simple test and, of course, therapy (hopefully in pill or cream form) to allow them to maintain, improve or just reestablish their libido. And after a long consult, and perhaps a few blood tests, I usually have to point out that libido is a many factorial issue…having to do with our physical health, mental health, (stress, fatigue, depression), self body image, partner availability, relationship with said partner, partner’s own sexual problems, medications (especially antidepressants) and yes our hormonal status. During the menopause transition we lose estrogen as we use up the finite number of follicles in our ovaries. Progesterone levels become nil, but if we have not had our ovaries surgically removed we still produce testosterone for several (some say 7 to 9) years to come.

Does desire dissipate as we become menopausal? If it does, is this due to age, the accumulation of the above mentioned factors or the loss of estrogen?

An attempt to answer these questions was made through a study supported by the National Institutes of Health (NIH), the National Institute of Aging (NIA) and the NIH Office of Research on Women’s Health. One more acronym, this was part of The Study of Women’s Health Across the Nation (SWAN). A total of 3,302 women were followed for 6 years as they went through menopause. (I love that it had 2 “extra” women, somehow this makes it more legit). They ranged from 42 to 52 years of age at the start of the study. The menopausal status of each woman was assessed at every visit. She was then given a 20 item questionnaire which included queries about the importance of sex, sexual desire, frequency of intercourse and/or masturbation, physical pleasure, emotional satisfaction with her partner, arousal and pain with intercourse. If menopausal she was asked about the frequency of hot flashes, night sweats and vaginal dryness in the past 2 weeks. And if sexually active she was asked if she used a lubricant in the past 6 months. Then she was asked about her overall health, whether she was recently married, divorced, separated, had a new relationship, and finally if she had any children living at home. Her BMI was calculated and she was tested for depressive symptoms. (As I write this, I wonder how they got 3,302 women to participate!)

The results: First let’s get to the importance of sex! More than 75% of the middle-aged women in the study reported that sex was moderately to extremely important. There was a decrease in sexual desire beginning in late perimenopause (when their cycles were intermittent and before they ceased having their periods for a year….this may be the appropriate time to mention that they only included women who still had their uterus and at least one ovary). These women also reported an increase in painful intercourse. But women in early perimenopause had a temporary increase in masturbation.
The long and short of all this…once the vaginal lining was not maintained by adequate ovarian estrogen production; it was not lubricated and “bestowed” with surging blood flow during arousal. Lack of vaginal engorgement and secretions led to a “diminished sense of pleasure from subjective arousal and a disruption in the intimacy-based sexual response cycle”. In other words if it hurt, and that ruined the mood. The authors felt that “the increase in masturbation during early perimenopause could be related to the concurrent increase in painful intercourse;” but that later on there was a decline in this masturbatory rate due to concurrent decline in desire.

Careful statistical analysis showed that the decrease in sexual desire was independent of chronological aging, menopausal symptoms, and health, social and psychological factors…and that the true sexual culprit appeared to be vaginal dryness. This was “highly associated with pain, lower arousal, emotional satisfaction and physical pleasure.”

Sexual functioning and vaginal “integrity” seem (at least according to this study) synonymous. What the study did not address is whether adding vaginal estrogen or hormone therapy will maintain a woman’s sexual desire and pleasure as she goes through her middle and later age. Most of my patients seem to think it does, (as long as all the other sexual reducing factors don’t overwhelm their ability to have or even consider enjoying sex). Unfortunately, but I cannot offer a 3,302 women, prospective statistical analysis. Hopefully future studies will.

Your daughter comes to see me…she has a boyfriend or perhaps already had one (or, and I know this is hard, several). She may be going off to college and she (or you) want to make sure she is prepared, not just with books or the latest in fashion, but with birth control. You probably want me to sternly reiterate those warnings about STD’s and the need to use condoms if (oi) she should become sexually active. This admonition may sound more authoritative from me than from either her teachers or you.

But should I do a Pap smear to “make sure everything is alright?” Or when she comes back from school and sees me a year later, and admits to sexual experiences, should I do it then?

We have heard a lot about cervical cancer and its cause, the human papilloma virus (HPV). To be succinct….there is no cervical cancer if there was no prior and usually ongoing HPV infection. (Remember when we were told that women who had never had sex would not get cervical cancer….we just didn’t know why, now we do; they were not exposed to HPV.) Well most of us have been exposed….the current estimate is that 50% of sexually active women in the United States will have a positive test result for HPV within 36 months of the onset of sexual activity. And because recurrent infections are also common, 57% of sexually active female adolescents (defined as a teens up to the age of 20) are infected with HPV at any one time. There are at least 30 types of HPV but thankfully, only some of them are high risk instigators of cervical cancer.

Here comes the good news… Eight months after initial infection the HPV usually becomes undetectable and in most adolescents with an intact immune system the infection resolves within 24 months.

Based on these facts, the American College of Obstetricians and Gynecologists (ACOG) does not recommend the use of HPV testing in this young population. (But they do recommend that adolescent girls and women up to the age of 26 receive the currently available HPV vaccine that builds immunity to 4 types of HPV….see my post on Gardasil). Moreover, there is no rush to do a Pap smear on these adolescents. Once more ACOG has come out with the recommendation that “the first Pap be done 3 years after the onset of vaginal intercourse and no later than age 21 and annually thereafter until age 30”

If perchance a PAP or HPV test was done before that and the HPV was positive, it should be ignored! If the Pap shows minimal abnormal cells (in technical terms ASC-US and LSIL) it should simply be followed since in most cases these changes will simply go away within 2 to 3 years. To make sure, ACOG s recommends doing a repeat Pap every 12 months for a 2 year period. Further testing with colposcopy and possible biopsy should be done only if these mild changes (termed CIN1 and CIN2) persist for 2 years or the Pap indicates more advanced “high grade” lesion (HSIL).

As with any STD diagnosis, the adolescent becomes an “immancipated minor” and parental consent for diagnosis and treatment, although preferred may not be required. (I generally ask my adolescent patients if I am “allowed” to talk to her parents, but will keep her privacy if she insists…especially if the test or therapy is not a threat to her health. Since most parents see the bill from the lab, complete confidentiality may be difficult).

So if you ask me to see your adolescent daughter, I, like most clinicians will sternly advise her about STD’s, the need for birth control and condoms. I probably will not do a Pap or HPV testing…until she is 21. And even at that age, I will “forgive” an HPV infection and/or mild changes in the cervical cells, but not ignore them. The plan will be to follow her with future Pap smears, HPV and STD testing.