With sexual concerns common after menopause, a form of talk therapy offers hope for improving libido and intimacy. Photo / Getty Images
Sexual concerns - from a lower libido to difficulty achieving orgasm or pain during sex - are common among women experiencing perimenopause and menopause.
After surgery thrust her into menopause at age 40, Stephanie Scott of Hamilton, Ontario said she had “zero sex drive”. target="_blank">Hormone treatments helped with hot flashes and insomnia, but they didn’t increase her desire for sex.
So she signed up for a research study testing a unique type of therapy for menopausal women with low desire because of menopause. The result: a noticeable improvement in her sex life.
“The focus was on reshaping your thoughts about your own body, your own needs and desires and desirability,” said Scott, now 49, who entered early menopause after having a hysterectomy and one ovary removed. She said the therapy helped her “understand the emotional and psychological changes going on during menopause”.
The results of the research, being presented Tuesday in Chicago at the annual meeting of the Menopause Society, suggest cognitive behavioural therapy - a specific form of talk therapy - can significantly improve sexual dysfunction problems related to perimenopause and menopause. Earlier research has shown CBT to be effective for hot flashes and other symptoms of menopause.
Sexual concerns due to decreased estrogen levels and other factors are reported by between 68 and 86% of women going through perimenopause and post-menopause, doctors and women’s health researchers say. These declines in function - from a lower libido to difficulty achieving orgasm or pain during sex - can undermine self-esteem and overall physical and emotional wellbeing, women report. But despite these negative impacts, treatment options (and, in particular, non-drug ones) are limited.
The new research included 30 women who took part in a treatment known as cognitive behavioural therapy (CBT). The participants completed four, 90-minute CBT sessions specifically tailored to address sexual function.
CBT is a form of talk therapy that encourages patients to identify and reframe negative thoughts and patterns, working to replace those with healthier alternative narratives. After undergoing the CBT sessions with a clinical psychologist, participants reported significant decreases in sexual concerns, researchers found, as well as improvements in body image and partner satisfaction, said Sheryl Green, the study’s lead author and a professor at McMaster University in Ontario.
One key goal of any type of CBT is to address deeply held distortions in thinking and, through discussion, exercises and practice, shift those negative beliefs toward more accurate and helpful ways of thinking.
For instance, a woman with no sex drive might believe her decreased level of desire will never change, which becomes a kind of self-fulfilling prophecy. The woman might decline the advances of a partner until the partner just stops trying to initiate intimacy altogether.
Green recalled one patient who “catastrophised” her hot flashes, believing they made her undesirable. But after CBT, which encourages open dialogue about sexual concerns with a partner, the patient learned her husband found her sweaty body quite sexy.
Exercises that address low sexual interest might involve thinking of things that increased desire in the past. “Maybe reading Fifty Shades of Grey built some desire in the past, or watching an intimate movie or engaging in sexting with a partner,” Green said. If it worked before, try it again, she said.
Scott, the Ontario patient who took part in the study, said the CBT sessions were “fantastic.”
She said one exercise involved getting dressed up and going out on a date with her partner without thinking that it might lead to sex. “There’s no pressure, you are just doing something for yourself, spending quality time together,” she said.
Talking honestly about her needs through the changing physical and emotional states triggered by menopause - and figuring out how to deal with them together - has helped normalise the transition.
“It works, but it takes work. It’s not magic,” she said. “We’ve engaged in sex a little more than we would have, and sometimes that involves just putting yourself out there, telling yourself this can be enjoyable.”
Notably, on the Female Sexual Dysfunction Index, a questionnaire considered the gold standard for measuring women’s sexual dysfunction, the mean score of study participants went from 15.88 before CBT treatment to 22.47 after CBT sessions - a 40% average improvement in scores, said Green, who is also a clinical and health psychologist. “That means they no longer fell into a clinically significant level of distress and dysfunction,” she said.
All of the participants, who ranged in age from 40 to 60, “indicated that they were very satisfied with the treatment and that it helped them cope with their symptoms more effectively”, the study found. Some of the greatest improvements were in desire and satisfaction, body image, and women’s perceived relationship with their partners.
Green said that to her knowledge, this is the first study to look at CBT specifically for sexual problems in both perimenopausal and post-menopausal women. One notable finding, she cited, is that even though the protocol targeted sexual concerns, there appeared to be “a trickle-down effect” that eased other common symptoms of menopause such as hot flashes, mood symptoms, depression and anxiety.
Green’s earlier work, including a randomised clinical trial, found CBT to be effective for the most well-known symptoms of menopause, such as hot flashes and night sweats, sleep disturbances, depression, as well as sexual concerns. She then decided to devise a CBT protocol focusing primarily on sexual dysfunction.
Stephanie Faubion, director of the Mayo Clinic’s Centre for Women’s Health in Enterprise, Florida, who was not involved in the study, said many of these menopause symptoms are interrelated, so alleviating one works to ease others. With sexual dysfunction, anxiety is often an issue, so if women experience anxiety, sleeplessness and stress over sexual dysfunction, and if CBT eases those symptoms, “of course the sex is going to get better”, said Faubion, who is also medical director for the Menopause Society. “Anxiety is a desire killer.”
One challenge is a shortage of therapists who practice CBT. Faubion said she and colleagues are working on virtual reality CBT for menopause symptoms, an approach that could alleviate some of the current barriers, such as time, cost and accessibility.
Sharon Bober, director of the sexual health programme at the Dana-Farber Cancer Institute in Boston and a professor at Harvard Medical School, said CBT “absolutely helps” menopausal patients regain desire and improve their sex lives. “I don’t think people know that it really works. It’s not made-up; there is clear evidence that CBT strategies have a direct impact on menopausal symptoms.” But it’s not used widely enough, she said, because the current state of menopause care “is often too medicalised”.
The power of CBT, Bober said, especially when combined with mindfulness practices to allow thoughts and feelings to emerge without judging them, is that you don’t condemn yourself for your negative thoughts nor deem them irrational; you just learn to live with them in a more accepting manner.
“The shift is about saying ‘it is what it is’ when you are freaking out about a hot flash, or your body not being how it was 30 years ago, and asking, ‘What can I do to calm myself, soothe myself and remind myself, this is not an irrational thought … Even though my body doesn’t look or feel like it used to, I can still give and receive pleasure’.”
The pilot study, funded by the Canadian Institutes of Health Research, is limited by its size and that most participants were White. Green said she is applying for new funding to begin a randomised controlled trial using the same CBT protocol to address sexual concerns in a larger group of 216 perimenopausal and post=menopausal women, including an active comparison group and a wider range of ethnicities.
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