SEXUALITY AND MENOPAUSE

A random online search on sexuality and menopause yields nothing other than bad news for the women in the fifth floor of their lives and beyond. This is quite a remarkable finding that serves to reinforce the notion that once women have achieved menopause, there is nothing really left to look forward to in their sexuality.

Back in my internship year, we admitted a 67 year old lady with what appeared to be a mild heart attack. Our ward had been on call and the morning after, it was extremely full and bustling with activity as we did the rounds with special attention to the new patients.

All newly admitted patients were offered counselling on HIV and those who consented were tested and results disclosed immediately by a specially trained team of counselors in the hospital. As the round went on, the counselor was right behind us carrying out the tests. When we saw the patient, we discussed her condition and planned her subsequent care as was protocol before moving on. She was stable at that time, pleasantly cheerful despite her discomfort.

We moved on to the next cubicle just as the counselor was getting to her bedside. An hour later, as we were winding up our round, a nurse called for help in resuscitating a patient. This was not uncommon in the first 24 hours after an admitting call as most patients were still highly unstable. My surprise was that we were called for this lady who had been chatting with us just an hour prior, seemingly quite stable. It was unsettling to say the least, to lose the battle to a heart attack as she left us unceremoniously.

As we drew the sheet over her face and the nurses wheeled her body away, the counselor drew me aside and let me know that her HIV screening test had turned positive but she had died before the news was broken to her. The news of her status drew mixed reactions from the medical team. This was back in 2007 when HIV was still running riot but more and more patients were accessing the life-saving anti-retroviral drugs. However, majority of the population on treatment were still just a few years old in the era of comprehensive care.

Our patient had displayed no symptoms of the infection hence this was an incidental finding on routine care. She had been widowed for 16 years and had no probable sexual partners known to her family. We debated briefly about disclosure of her status to her children but rapidly agreed that since the diagnosis had not contributed directly to her death, and the patient herself had died without being aware of her status, we had no right to disclose the information.

However, the unspoken question hung in the air for some in the team; how a post-menopausal widowed lady was possibly sexually active. Majority of HIV infections in Kenya among adults are known to result from sexual transmission among heterosexual partners, hence the assumption on how she could have acquired the infection.

A few years later, a friend brought her mother to our clinic for an annual wellness check-up. The mother had steadfastly refused to have a pap smear done and my friend was exasperated. As she stepped out of the room, she wished me luck. The patient was 57 years and though initially shy, we were able to strike up a good rapport as she opened up. I was impressed when she raised the issue without prompting, asking if it was normal to have sexual desire at her age, especially since she had been widowed for the past five years. This was definitely a refreshing conversation and ultimately she did agree to have her first Pap smear test done!

The two incidents left me thinking about the assumptions made about sexuality in the menopausal age group of women. Very few doctors ask their patients about their sexuality yet it is an integral aspect of health. It is assumed that these women gradually lose interest in sex and this loss seems to have been accepted as the norm, rather than be viewed for what it is, a female sexual dysfunction.

It is estimated that among all women, the prevalence of sexual dysfunction is 25% to 63%. This rises to 68% to 86% in the post-menopausal group. Coupled with the fact that most doctors do not ask about it and most women will hardly raise the issue during a medical consultation, let alone seek for help, the condition becomes accepted as a normal state. It is therefore not surprising that women like my patient, who fall in the 14%-32% bracket of normal function are regarded as the “abnormal” ones.

Menopause comes with change in hormonal levels, significantly the lowering of estrogen and testosterone, a state which precipitates sexual dysfunction. Yes, all women have small amounts of testosterone in their system that serves to boost libido. After menopause, as these levels decline, it may result in lowering of sexual desire, sexual response, arousability and attaining of orgasm. The low estrogen levels may result in vaginal dryness, vaginal wall thinning hence easier bruising, decreased sensation, all resulting in painful intercourse.

It is important to note that before sexual dysfunction is pinned on menopause, that the doctor needs to ensure that it is not as a result of medical conditions such as diabetes, heart disease, urinary tract infections and even depression. It may also result from the use of certain medications and negative body image.

It is therefore imperative that we flip the card and assign the correct narrative. Normal post-menopausal women have a right to enjoy complete sexual health, to desire sex and to enjoy it. It is not a disorder and neither is it a moral issue. For women struggling with sexual dysfunction, there is plenty that can be done to manage the condition and attain an acceptable standard of sexual health. Their basket is already full with arthritis, sciatica and other old-age ailments they may not have control over. At least let us eliminate the one problem we can!