Women’s sexual health is important for both their physical and mental well-being. The challenge is women are often too embarrassed or reticent to discuss issues impacting their sex life with their doctors. Societal norms are still part of the problem, but sexual health problems can be managed with the help of a gynecologist.
To learn more, we continued our candid discussion with Dr. Julie Thorne, the current family planning lead for Women’s College Hospital and Mt Sinai Hospital in Toronto. She provided information on everything from the importance of speaking with your healthcare provider about your sexual health to sex after pregnancy and managing pain during intercourse after menopause. She also shared her thoughts on how the pandemic impacted women’s sexual health.
What are the main reasons that women have for not bringing up intimacy issues with their doctors?
This is really important and it’s something that I feel very comfortable talking to my patients about. Not all doctors will talk about it and not all patients will bring it up with their doctors. Women’s sexuality and their enjoyment of sex has been suppressed in our Western culture for a very long time. There is societal stigma around the word sexuality and caring about intimacy or talking about it is still seen as shameful. Even just around what anatomy is normal. I see a number of women who feel the anatomy of their vulva is not normal because it doesn’t look like what they have seen on TV or porn. They do not realize the breadth of what is normal for women’s anatomy.
There are also some interesting beliefs about sex being a conjugal duty rather than for mutual enjoyment, self-enjoyment or for fostering a caring relationship. They are not correct, but we don’t talk about it or make it ok. The converse of that, is that I think a lot of healthcare providers are not comfortable with what advice to give around intimacy issues and that is on us. We need to do a better job as providers to talk about sex and what to do to make it better. That further creates that barrier to conversation with your patient.
How do you get those details out of a woman when you may not hear about it until she has pain during intercourse?
I’m a gynecologist and I usually see people when we are talking about an issue with their gynecologic health that might be pain driven. When they are talking to their healthcare provider, part of that visit should include questions like, “Are you having sex? Is it enjoyable for you? Are you having any concerns about it?”
When I talk about pain during sex, we are trying to move away from talking about sex in itself as a cycle because we know for women that it isn’t necessarily circular in that way. We try to get into the different pieces that can impact the pure enjoyment of sex. Some of the problems can be relationship issues, state of arousal, it can be expectation, it can be tension that is happening in that moment. It creates this opportunity to talk about different kinds of sex and different ways of having enjoyment whether it’s by yourself or with a partner. Making that a normal question can open up that conversation.
Women often don’t think about sex after pregnancy and how delivering a baby will change their bodies aside from weight gain. What changes do happen? What can women do to ease back into sex and when should they talk to their doctor?
Some of that will be a mind over matter thing and I’m not going to place all of that on the woman that has a child. We don’t celebrate women’s bodies enough and the changes that they go through. It’s not possible to maintain yourself like a perfect model when you have had a pregnancy. As your body changes, it remains beautiful. We have to think about how we support that positive affirmation and the fact that they remain attractive to other people as well. There are some physical changes that make it harder that need to be addressed. When a woman is breastfeeding, especially, the vagina can be really dry and sometimes the woman will need to speak with a healthcare provider about that.
Sometimes there can be a tear that can heal well or there can be scar tissue that’s problematic. The function of the pelvic floor changes and that’s where I really believe that all women can benefit from pelvic physiotherapy. It can address some of those typical changes that happen after childbirth.
When you have a baby, you are sleep deprived. You are juggling with the stress of having a baby and you have other kids too, getting into the zone and creating that time to making sex and intimacy a priority is really hard. That’s where you have to ask yourself how to create your life to have intimacy with your partner, make that time and not put pressure on each other to have sex again. It can be taking small steps in stages. There is a lot of anticipation for women about having penetrative sex or having anything in the vagina after a delivery. Think about how you slowly build up to that place where you are ok with intercourse because you already have enjoyed other types of sexual intimacy.
Menopause also brings changes to a woman’s body like vaginal dryness, painful sex (possibly) and lower libidos. What are some steps that a woman can take to help ease these symptoms?
Continuing to have sexual activity is important. Since the vagina becomes low in estrogen, it becomes very common for women to have atrophy and symptoms of dryness, irritation or urinary problems in menopause, and that can impact their sexual function even if they still have desire. There are some medical therapies to deal with that. Practice good feminine hygiene by not using irritants around the genital area and using lubricants for sex can help. There are some women that lose their libido or they stop valuing intercourse as a means of expressing intimacy and that has to be ok too.
As women transition into menopause, menstrual abnormalities are really common. Some things that they may have had before all of a sudden express themselves in a much stronger way. Maybe they had heavier periods because they had fibroids, and it can get a lot worse as they approach menopause. We can manage some of those symptoms with things like contraceptives. As you transition into menopause, you can still get pregnant and people forget that. It is another benefit of contraception.
Sexual health has a huge emotional impact on women regardless of their stage of life and hormones are often blamed as the entire cause. When should women look at adding therapy to bridge the gap?
This is a broad question. It depends on which stage of life that we are talking about and what we are specifically talking about. I think that periods of stress are really important to consider. For some women that come to me for pelvic pain, for example, we have been able to identify that stresses of the past year and the emotional toll that it’s taking has really impacted the pain that they feel. That mind/body connection is really important. That’s an example of when women can benefit from speaking with a counselor.
There are cyclic symptoms that can impact your life and add stress, but they can be managed. For example, people with heavy periods sometimes have low iron and they become fatigued. They can’t concentrate, they can’t complete their jobs properly, they don’t want to get out of bed and they get short of breath when they are walking. All of these symptoms may have an emotional toll because they think that something is wrong and they get irritated with their partners. We can manage that with contraceptives even if pregnancy prevention is not the primary reason that we are using it.
What impact have you seen from the pandemic on women’s sexual health?
Everybody’s lives have been turned upside down. We joked that when the pandemic first started, that we would have a baby boom because everyone was at home, but that’s proven not to be true. It’s been a really stressful year with some people losing their job. They are all at home, their kids have either been out of school or they have to homeschool them while trying to do their job. Many people did not have the ability to go out and do the things that they need to because they couldn’t leave their house. They lost their social contacts so this has had an incredible impact on everyone and that trickles down to their sexual health.
No one wants to have sex or they can’t fill their contraceptives because they can’t get to a pharmacy or the pharmacy doesn’t have enough supply. They feel afraid to go to the doctor, call their doctor or they don’t feel that their doctor is as accessible. All of those things trickle back to how regular their menstrual cycle is, how they are feeling during their menstrual cycle and whether or not they have any interest in intimacy and how they are feeling about their bodies. I can say that the impact has been significant.
Read Part 1 of our interview with Dr. Thorne to learn more about contraception, how it can help a woman do more than prevent pregnancy and why it’s such a political hot button in 2021.