Sexual wellness

Sexual wellness is how comfortable, wanted and like yourself you feel in your intimate life. In the menopause years it can shift in a few ways at once.

There is desire, which can fade or change. NICE NG23 names low sexual desire among the symptoms clinicians should explain to women at this stage. There is the body: the Pakistan Menopause Society lists vaginal dryness, burning, irritation, loss of lubrication and pain during sex among the symptoms of the first years after the menopause, part of what doctors call GSM, the genitourinary syndrome of menopause. And there is arousal and orgasm, which the PMS lists as well.

Not wanting to, and not knowing why. Wanting to, but bracing for it to hurt. Feeling dry, sore or raw afterwards. Lying awake worrying about what your husband is thinking. Feeling that something has gone from you that you did not agree to lose.

When the loss of desire is persistent and distressing, and nothing else explains it, the PMS gives it a clinical name: hypoactive sexual desire disorder (section 1.5.3). A name can make it easier to raise.

The Pakistan Menopause Society links GSM to the fall in estrogen and other sex hormones, with changes to the vulva, vagina, urethra and bladder. Low libido can be part of the same picture. The PMS definition of the clinical condition says the loss of desire is not better explained by something else, which is why a doctor will also ask about your sleep, mood, stress and any pain.

You are in large company. The European Menopause and Andropause Society (EMAS) says around one in two women have sexual problems. It also counts a partner's own sexual problems, such as erectile difficulties, among the causes after the menopause, and asks doctors to include them when they assess a woman. Sometimes the change is not only yours.

• NICE NG23 recommends offering vaginal estrogen for genitourinary symptoms, vaginal dryness included, and says moisturisers and lubricants can be used with it or on their own, including by women who cannot use it or prefer not to (1.5.5, 1.5.8 and 1.5.9).
• Women's Health Concern, for the British Menopause Society, lists local estrogen among the treatments for vaginal dryness, and says lubricants and moisturisers can be useful, especially for women for whom estrogen is not suitable.
• The Pakistan Menopause Society says moisturisers can be used regularly, not only around sex, for a longer-lasting effect, and that water-based and silicone-based products are preferred over glycerine-based ones (section 6.2).
• The Menopause Society, in the US, suggests trying a new lubricant or moisturiser on a small patch of skin before using it inside. If it passes on the skin but still stings in the vagina, it suggests switching to a silicone-based product, or one labelled iso-osmolar or free of propylene glycol.
• The NHS website says moisturisers and lubricants are sold in pharmacies without a prescription, and that oil-based lubricants can damage condoms.
• The PMS counts better sexual wellbeing among the benefits of lifestyle changes in these years (section 4.2).

A doctor can also prescribe treatment. The NHS website lists HRT and hormonal treatments placed in the vagina, such as creams, pessaries, gels or rings, for vaginal dryness; see vaginal estrogen.

For low desire, NICE NG23 has one recommendation (1.5.25): "Consider testosterone supplementation for people with low sexual desire associated with menopause if HRT alone is not effective." NICE notes that in 2015 this was an off-label use. The Pakistan Menopause Society takes the same order, HRT first, then testosterone considered for persistent low desire (section 5.9). Whether either is right for you depends on your health and history, and that is your doctor's decision.

Book an appointment if sex hurts, if dryness or soreness is getting in the way of daily life, or if a change in desire is upsetting you. If you would feel easier with a woman doctor, ask whether one is available. The PMS asks doctors to ask about these symptoms in privacy, and to refer women on for persistent pain, repeated urine infections or signs of prolapse (Table 2).

See a doctor promptly about any bleeding after sex. The Pakistan Menopause Society lists post-coital bleeding, and bleeding after your periods have stopped, among the red flags that need checking (section 2.3).

Within a marriage, intimacy carries faith and duty as well as feeling, and women have questions about it they rarely say aloud. Those questions belong with a qualified scholar you trust, and Roshara does not answer them.

What the guidance does say is that the husband is part of this. The PMS asks for honest talk about hormonal changes, respect for sexual health and personal space, encouragement of a positive body image, and seeking professional help without stigma (section 4.2.6). See partner and family support.

NHS inform, Scotland's NHS health information site, has a page on sexual wellbeing, intimacy and menopause, with a version in Urdu. It is linked in the sources below.