Dr. Di Pace, how deep is the link between a woman’s overall physical and mental health and her intimate life, especially as she approaches menopause?
The two spheres are closely interconnected. If a person is in good physical and psychological health, they will almost certainly have a better disposition toward sexual activity. At the same time, a satisfying sex life acts as a powerful driver of mood, self-esteem and overall energy. As the World Health Organization (WHO) has also stated, sexual well-being is an integral part of overall health. Menopause, like other life events, for example an illness, disrupts psychophysical and sexual balance: priorities often change, and sex takes a back seat. In these cases, however, it is important to remind patients that sexuality is a fundamental part of overall well-being, and to help them regain it at the pace and in the ways best suited to their situation at the time.
What are the real physical and psychological causes of the changes in sexuality during menopause?
The sexual problems that emerge in menopause can be traced mainly to three broad categories: anatomical, hormonal and psychological. From an anatomical standpoint, the drop in estrogen causes profound changes such as thinning of the mucosa, loss of elasticity of the vagina and reduced lubrication, leading to what we call the genitourinary syndrome of menopause. This often results in dryness and pain during intercourse, factors that naturally dampen desire. The hormonal component, on the other hand, concerns not only estrogens but also the decline in androgens such as testosterone and dehydroepiandrosterone (DHEA), produced partly by the ovaries and partly by the adrenal glands, which directly affect sex drive. Finally, there is the psychological aspect linked to bodily changes: weight gain and the different distribution of body fat can alter self-perception. If a woman no longer perceives herself as desirable, her own desire will inevitably suffer too. Restoring sexuality means acting on all three areas.
So are there several treatment options available today to address these problems?
Yes, as far as the anatomical area is concerned, for example, we can use hormone therapies that are both systemic — HRT, which we have already discussed (read the first part of the interview with Dr. Di Pace here) — and topical. Topical hormone therapies, in the form of creams or vaginal suppositories, are one of the most effective and fastest solutions for improving the quality of vaginal tissue and restoring lubrication. It is essential to reassure women that these hormones, acting locally, do not increase the risk of cancer, not even breast cancer. These treatments are often long-term, because if they are stopped, the lack of natural hormones will quickly return the tissues to their previous state. Topical hormone therapy for vaginal atrophy can be successfully integrated into a multimodal approach that also includes physical technologies.
What is meant by physical technologies for menopause?
These are “devices“, equipment that uses physical stimuli to induce tissue regeneration. The vaginal laser is one example: it can be ablative, like the CO2 laser that creates micro-perforations in the mucosa, or non-ablative; in both cases, the aim is to induce a very small, controlled injury that stimulates the production of new collagen and elastin, regenerating the tissue. Radiofrequency, on the other hand, uses electromagnetic waves to raise tissue temperature slightly, producing a remodeling effect and greater tone. Another emerging option is oxygen-ozone therapy, which stimulates the cells of the mucosa through high concentrations of oxygen. These treatments are generally not painful and are well tolerated, and no particular precautions are needed after the procedure, other than abstaining from sexual intercourse that day. Treatment involves cycles of a few sessions, with benefits lasting from 18 to 24 months depending on the individual response. Note, however, that while a hormone treatment can be combined with a physical one, two different devices cannot be used in the same period. If appropriate, once a cycle is completed, it is possible to decide with the specialist how to proceed.
Some women do not want to take hormones or, like cancer patients, cannot. Are these technologies suitable for them too?
Absolutely yes, and it is one of their most important areas of application. For women with a history of hormone-sensitive tumors, for whom there are no conclusive data on the safety of vaginal hormone therapies, physical devices represent a valid and safe alternative. The scientific literature of the past ten years has confirmed the efficacy and safety of laser and radiofrequency precisely in these patients, allowing them to treat atrophy without systemic risks. Consider that the first laser for vaginal use was introduced in 2014, and since then studies have multiplied, showing objective improvements in vaginal health parameters and in overall sexual function.
Menopause can bring aesthetic changes. The most visible are usually weight gain and fat redistribution, but something also happens at the intimate level. How can this be addressed?
That’s true: the aesthetics of the vulva also change in menopause, for example with loss of volume in the labia majora or thinning of the labia minora, factors that can affect self-perception and the function of the vaginal opening. Today we use techniques borrowed from aesthetic medicine, such as biorevitalization with hyaluronic acid and amino acidsAmino acids are the basic substances that make up proteins. Each protein is characterized by a precise sequence of amino acid "bricks". Some are produced by the body by processing food, others, which the body cannot synthesize, must be taken directly with food., which rejuvenates the dermis and improves its function. There are also vulvar fillers, useful for restoring tone and volume where natural fat has decreased with age. The most advanced frontier, however, is regenerative medicine, which uses stem cells taken from the patient’s own fat, or PRP (platelet-rich plasma), to regenerate tissue affected by conditions such as lichen sclerosus, or for purely aesthetic and functional purposes. While local anesthetics are used for biorevitalization and fillers to reduce discomfort, regenerative medicine techniques require sedation, and recovery after the procedure also calls for greater care.
Another crucial topic is the pelvic floor. How do pelvic floor problems affect sexual life and everyday health?
With menopause (though not only then), the pelvic floor can undergo two opposite types of change: hypertonicity and hypotonicity. Hypertonicity often develops as a reflex response to the pain during intercourse caused by atrophy: the woman feels pain, the muscles contract, and a vicious circle sets in that can also lead to vulvodynia and urination problems. Hypotonicity, by contrast, is linked to the loss of elastic fibers and can cause prolapse or urinary incontinence. In both cases, rehabilitation is essential. The gynecologist’s role is to diagnose the problem, but they usually do not act alone and refer the patient to supporting professionals who, through specific exercises, manual therapy and the correct use of diaphragmatic breathing, teach the woman to regain voluntary control of these muscles, improving both continence and the pleasure of intercourse. There are several professionals to turn to, from midwives to physical therapists and osteopaths, but all must have specific training. The approach differs depending on the professional: a midwife can perform internal manual therapy, a physical therapist works a great deal on breathing, and an osteopath works mainly externally. Devices can also help with pelvic floor recovery, but while radiofrequency and oxygen-ozone therapy can also be performed by midwives and physical therapists, the vaginal laser remains the domain of the specialized gynecologist.
Women often find it hard to talk about these issues with their doctor. What is your advice on choosing a specialist?
It is a fact that about 40% of women with sexual problems in menopause do not receive a solution, often because doctors do not ask the right questions or because patients feel embarrassed. For complex problems of desire or sexual function, the ideal would be to see a gynecologist who is also a clinical sexologist. While a traditional gynecologist tends to look only at the physical aspect, a gynecologist-sexologist also assesses the psychological and relational component, which plays a crucial role in female desire. Let us also remember that sexuality involves the couple, and that the male partner may also have age-related problems, and it is therefore important to consider sexual health in terms of shared well-being, turning, if necessary, to a psychologist-sexologist or even to an andrologist.
To conclude, what key messages and practical advice would you like to leave women with?
The most important message is that menopause is by no means an end, but the beginning of a new phase of life that can last a third of one’s entire lifetime and be just as interesting as the one before. As for intimate longevity, this is what I always recommend: using a suitable intimate cleanser, regularly applying moisturizers or local hormone products to keep the tissues healthy and, above all, maintaining a positive attitude toward sexuality. Taking care of one’s general health and keeping healthy habits helps preserve a sense of oneself as desirable and active.
Read the first part of the interview with Dr. Di Pace here:
The Whole Truth About Menopause (and Why It Shouldn’t Scare Us)
