Sex is Important: An Interview with Dr. Holly Thomas

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While at the North American Menopause Society Conference last month, I had the opportunity to interview Dr. Holly Thomas, who specializes in menopause and sexuality. Dr. Thomas, MD, MS, is an Assistant Professor of Medicine, University of Pittsburgh

Madeleine Burnside: Please tell me something about your work.

Holly Thomas: Certainly. I’m a primary care doctor by training, I also have special education training in women’s health, and so obviously issues surrounding menopause come up frequently for me from a clinical standpoint. My program of research focuses around sexuality of women in midlife and older age, and how that may or may not change as women move through their midlife transition.

MB What kinds of changes in sexuality?

HT Well, the longitudinal studies that we’ve seen have been valuable in using survey work to ask people a variety of questions about what they may be experiencing. Those studies have shown that some aspects of sex do certainly decline as women move through the midlife years. The common symptoms women often complain about include low libido, longer periods of time to become aroused or reach orgasm, and vaginal dryness and pain-related effects, and most three-year longitudinal studies demonstrate that those symptoms do worsen, particularly around and beyond menopause.

Your work with women telling their stories is interesting, and it’s part of what we wanted to do with this current survey. Usually, the investigator comes up with a list of questions for which the participants are asked to select a single answer, and it’s a little like putting words in their mouths because none of the answers may fully reflect what they’re going through, and they might respond with the answer that most closely but doesn’t fully or clearly describe their experience; and sometimes more than one answer to the same question would better reflect their experience. In this study we’re using a qualitative methodology with open-ended prompts that allow women to use their own words and narrative to describe their experiences. This allows us to capture some of the nuances that perhaps we’d otherwise not get from a written survey, and it also allows women’s personal stories to shine through.

Some of our findings were not too surprising for us—for example complaints about libido and vaginal dryness—but one of the things we were interested in seeing was what women attributed these changes to. A lot of the medical research has focused on menopause itself and hormones and their effects on sexuality, and while some women in this study did follow that model, we found women were more likely to cite life changes than physiological changes as reasons for sex falling off during their midlife years. We had a number of women talk about being busy with careers or social roles, problems with adult children or taking care of ageing parents, and high levels of stress as reasons for the decline in their sexual activity. It was an interesting finding to see that women don’t necessarily attribute these sexuality shifts to menopause, rather they feel that some of it is due to other things going on in their lives. Something else we found that somewhat goes against the existing survey work is that there were a number of women who actually felt sex had gotten better for them.

MB I was going to ask you about that last point, because I have come across stories of hyper-sexuality where women become suddenly really interested in sex.

HT Yes, and women had a variety of reasons for feeling this way. For some women, if they’ve gotten divorced in their 40s and are starting a new relationship, that may jump start their libido; but even for women who are in longer term relationships there are reasons why they felt that sex had improved, and many women were just feeling more self-confident and comfortable in their own bodies in their 40s and 50s than when they were younger, which allows them to be freer in their sexual expression. A second thing women talked about in terms of positive changes was having a better understanding of themselves and their own bodies; many of these women felt they hadn’t known their bodies sexually when they were in their 20s and 30s, and that they were now in a position which allowed them to convey what they wanted to their partners in a more meaningful way. And that goes into the third reason for women saying their sex lives had improved, which is that their communication skills had evolved and they were more able to speak up to their partner about what was working for them or not.

MB I have seen in Dr Christiane Northrup’s book The Wisdom of Menopause cases of women changing their sexuality from straight to gay or gay to straight. Is this something you’ve come across?

HT It’s generally thought that female sexuality is more fluid than male sexuality. In my own research I haven’t necessarily heard of people discussing that problem, but it may be under examined.

MB I’ve talked to a friend of mine who is a doctor about it, and it could be hormonal around puberty for both sexes; but I’ve talked to two women who have both changed their sexuality in menopause, one from gay to straight and the other from straight to gay, and it’s an irresistible hormonal change. I grew up in the era when we thought that sexuality was very fixed, but what I know now leads me to believe that bisexuality truly exists. I have seen women who were theoretically happily married run off with the golf coach who happened to be a woman.

HT Well, I’ve seen it in my personal life. And I wonder too if, aside from the hormonal element, it might be that those feelings of increased self-confidence and sexual expression we found in our own study could play a role; perhaps some of the urges or desires that were there before had been suppressed, and now that they’re a bit older they feel freer and more confident to express them. It’s something that should be explored more.

MB I do find, though, that many people leave their partner, and they will say to me that it had nothing to do with going through the change—rather there may have been years where things weren’t so good or they grew apart or their kids were in college and they were able to leave in a more graceful way or they met somebody else—and it always falls right at that midlife point. Is it because they’re more confident, or is there something in that irritation scale where they simply say they can’t tolerate this for one more day? And I also find that people who don’t have any problems with their partners will change jobs, usually out of frustration with a lack of personal fulfillment or advancement, yet again it’s entirely unrelated in their own minds to menopause. In my observation, regardless of what form it takes, people more often than not make big changes around that time.

HT It may be that people pause for reflection, look back and take stock and say what do I want my life to look like at this point.

MB I know you’re giving a very interesting talk here at the conference, could you tell me something about that?

HT I’ll be talking about both the negative and positive changes women experience. Among the things that came up for the people in our study were issues with their sexual partners, who were majority male. In terms of negative impacts on their own sexuality, women talked about developing relationship discord with male partners, and seeing their partners develop health problems like diabetes or prostate cancer that led to sexual dysfunction. Another issue that this study reminds us of is that we cannot observe women in a vacuum—sex is almost always occurring with another person, and whatever’s going on with a partner will inevitably influence the mutual dynamic. Male erectile dysfunction was a big problem in relationships. Now that these women are older and slower to arouse and reach orgasm, their partners are unable to maintain an erection as long as they used to, so you have a perfect storm of symptoms between male and female working against each other. Most of these women hadn’t thought of other types of sexual activity and still placed primary importance on penetrative penis-in-vagina intercourse as their goal. Much of the time we think of the male as the initiator of sex across the lifespan, but we found that some of these women were urging their partners to see their doctors for blood work or to get prescriptions for Viagra. The other interesting finding was that a number of women reported that their male partners had developed problems with libido as they grew older, and they found themselves often in the position of being the initiator of sex, which is contrary to our standard perception; it was frustrating for the women who found their libido increasing at that time in their lives.

MB There was a recent story about a well-known female tennis player, Chris Evert, who just had an affair with her husband’s best friend and blamed it on menopause. It sounded like her married sex life really declined while her libido surged, which I certainly have heard a great deal about. It was tragic for her husband, as far as I’m concerned, because you don’t want to lose your wife and your best friend at the same time in that kind of way.

HT Well, there were a few women in this study who did talk about noticing increased libido after a hysterectomy or once their menstrual cycle stopped, which again was surprising to us. It reminds us that sexuality is complex and diverse, so trying to make broad generalizations about what happens to sex in midlife is tough because it’s so individual and variation is the norm. It’s not only hormonal, and needs to be seen in relation to the conditions of individual life and shared culture.

MB How did you get started in your line of research?

HT I’m 34 years old now and started doing this work over ten years ago. As a primary care doctor I’m interested in the whole patient, I want to make sure that overall the patient’s wellbeing is maximized. And I think issues of sex have impacts on both body and mind, and so my holistic approach also lends itself well to a complex issue like sex and aging.

MB Is there anything else that you’d like to tell the lay people who read Sanity Papers?

HT One message I’d like to convey is for women not to be afraid to discuss these things with their doctors or other healthcare providers, because we do have treatments for many different types of sexual issues. Sex is important to many people and has an impact on relationships and quality of life. In our culture we try to deemphasize sex and say that relationships should be about love and respect, but sex is a big part of that too, and women shouldn’t be ashamed to make that a priority or ask for help. Menopause is a universal experience for all women who live long enough—it’s not like diabetes or heart disease that not all women go through. Proper training for providers is hugely important so that when women go to their doctors they’re dealing with someone who has useful clinical and practical knowledge and experience.

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