Thriving through midlife for the aging female: Menopause, sexual health and wellness

Women’s Health Week falls in May—a perfect time to talk about the menopause experience, and how it affects our bodies and our sexual health.

On this episode of Aging Forward, Dr. Carol Kuhle talks about how perimenopause can be a confusing time for women, emerging treatments for menopause symptoms, and how vibrators can be a useful tool for vaginal health.

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Dr. Christina Chen: This is “Aging Forward,” a podcast from Mayo Clinic about the science behind healthy aging and longevity. Each episode, we explore new ways to take care of our long term health, the health of our loved ones, and our community, so we can all live longer and better. I’m Dr. Christina Chen, a geriatrician and internist at Mayo Clinic in Rochester, Minnesota. In this episode, we’re talking about Menopause.

Menopause typically affects a woman around the ages between 45 and 55 years old, marking the end of her reproductive years. With it comes the end of her period, too, and a decrease in estrogen and progesterone production, which can lead to a lot of changes in the body. That menopausal period comes after perimenopause, a transition phase where hormones can fluctuate.

This can be a very confusing time for a lot of women, because it can be hard to identify, can possibly start somewhere in your late 30s or 40s, and symptoms often get mixed up with a lot of different things we experience on a day-to-day basis.

Today, we’re going to talk all about the menopause experience: the effects it has on our body, and in particular, our sexual health. Our guest is Dr. Carol Kuhle, a consultant in the division of General Internal Medicine at Mayo Clinic in Rochester, Minnesota. She was also the director of the Menopause and Women’s Sexual Health Clinic for eight years. Welcome to the podcast, Dr. Kuhle.

Dr. Carol Kuhle: This is wonderful.

Dr. Christina Chen:  I am 42 this year, and whenever I tell my older female patients that I’m 42,  they just sort of look at me and chuckle and they’re like, “Oh, you have no idea what’s coming.”

It gets me thinking, what is next? When we start heading into that perimenopausal  transition, what does that look like for women?

Dr. Carol Kuhle: I mean, when you’re looking at the perimenopausal time, that’s a time when the ovaries start to decline, but they don’t just turn off, they’re on one day, off the next. The main thing in the midlife piece is, what are those vasomotor symptoms? Eighty percent of women will have them, hot flashes and night sweats.

Women will tell you they have terrible hot flashes and night sweats, and that all of a sudden they feel a little bit better because their estrogen went back up. They get their menstrual cycle.

Dr. Christina Chen:   Just to define some terms, vasomotor symptoms refers to the changes in blood vessel activity, which can cause a feeling of intense heat, sweating, and sometimes a subsequent chill.

Dr. Carol Kuhle: Then looking at who has hot flashes, who doesn’t have hot flashes, and why we say 80 percent of women will have some kind of vasomotor symptom. There’s this database that is watching women over years and years and years, and you can see that some women never have a hot flash.

Some women will get tons of hot flashes and then it’ll wane off. Some women will start getting hot flashes and they’ll just keep on getting them. This can happen over a period of time and sometimes that is really a challenging time. We want women to recognize that yes, you can be treated for this.

Dr. Christina Chen: We have to understand the nature of your symptoms so we can help treat it early. It’s important to talk about it.

Dr. Carol Kuhle: This is the thing that really bothers women a lot. They’ll have the weight thing. They’re getting that weight and we tell them that aging collides with menopause. You’re having to do more, eat less to stay the same, but then you have this weight that comes around the tummy that’s more related to estrogen than it is related to aging.

Dr. Christina Chen: We’re talking specifically about the drop in estrogen that happens during this time, which can lead to that weight gain. Some women may start to mitigate that by taking estrogen supplements.

Dr. Carol Kuhle: Right. Women struggle with that so much. Estrogen can help a little bit, but it’s not a weight loss medication. Then of course bone health going forward is huge because women will precipitously lose bone when they go through menopause and lack of estrogen.

Capturing that becomes really important, because we can treat that and that can prevent fractures down the road. Because as a geriatrician, that one fall, one hip fracture…

Dr. Christina Chen: It’s bad news.

Dr. Carol Kuhle: Mortality within the next year.

Dr. Christina Chen: For people who are going to their primary care for the first time and perhaps discussing these symptoms for the first time, is there a role in checking hormones?

Dr. Carol Kuhle: We have this conversation frequently because people come in one, with 10 pages of lab work. If a woman is without a menstrual cycle for a year or going through that period of time, they’re of the age of being menopausal.

They’re having symptoms. It appears that this is related to lack of estrogen. We don’t even check a level. We really don’t. The time we’ll do it is if there’s some question. I mean, we’ll check a thyroid sometimes just to make sure that’s not going on. If it’s just night sweats, then that’s a whole nother conversation.

We frequently do overnight pulse oximeters because we do pick up sleep apnea in our clinic all the time. When we check them is when somebody’s younger and we’re not sure where they are. But the question is when somebody’s perimenopausal, when do you check it? Because it could be all over the place.

If somebody’s had a uterine ablation or they have a Mirena IUD in and we’re not sure, it’s navigable, but it’s not standard because we don’t know that it’s going to help us.

Dr. Christina Chen: Okay. We’ve talked about hormone changes, weight fluctuations, and bone health. How else does menopause impact us when it comes to physical cognitive health and social health? How does it impact wellbeing as a whole?

Dr. Carol Kuhle: Women will say they just don’t feel like themselves. This brain fog thing that they complain about, that’s really important to identify. It’s not that they’re at risk for dementia if they have brain fog. The brain fog is more associated with the sleep issues and the insomnia and the night sweats.

Once we can help that, they will say, I feel like myself again, my brain is cleared, I’m functioning better, in that aspect. The other piece is then the sexual health piece, where the vagina and the vulva have estrogen receptors and that starts to thin out. Unlike hot flashes, we hope hot flashes will go away over a period of time, and that may, or may not. But those symptoms around the vulva just get worse over time.

Dr. Christina Chen:  When it comes to common vasomotor symptoms, like the sleep issues and the weight changes and mood changes, is there one that typically starts first? Because we see a lot of women in their late thirties, and they may experience all of that at once. How do you differentiate between what’s menopause, and if it’s something completely different?

Dr. Carol Kuhle: Oftentimes we’ll have somebody come in and say, is this menopause? I’m having all these symptoms, is it or is it not? Helping them discern if they’ve gained weight, do they have sleep apnea? We pick that up all the time.

It’s that they’re having night sweats, but not daytime sweats. Then we worry about, is there something else that’s driving this? We check the thyroid. It’s not uncommon that women will come in with night sweats and we’re like, “This is not menopause. We need to work you up for something else.” Oftentimes we will find some other underlying cause.

Dr. Christina Chen:  Are we seeing menopause happen earlier now?  Is there a trend towards people getting it at a younger age?

Dr. Carol Kuhle: I would not say that. I would say that our awareness [is heightened] and we put it in buckets and it’s really important to identify where a woman is because we have that perimenopausal time.

You can go through that perimenopausal time where you’re having irregular periods, but you’ve not gone a whole 12 months without a period, because that’s the definition of menopause. There’s that group.

During menopause the average age is between 45 and 55. Then there’s that group that’s under 45. We call that early menopause. Then there’s that group that’s under 40, which is primary ovarian failure.

It’s really important for us to identify those women that are under 45, and especially those women that are under 40, because they absolutely need hormone therapy. If they don’t get it, their outcomes later are bad. They’ll have increased risk for dementia, increased risk for cardiovascular disease, increased risk for bone health, not to mention sexual health.

Then there’s the induced menopause. That’s a whole nother category of women who have cancer. They go through radiation, they go through chemotherapy. They are put into menopause early, and they also need that support, and who can have hormone therapy, who cannot, and how do we help them with their sexual health issues?

Dr. Christina Chen: Can we talk a little bit about heart health and cardiovascular risk? In terms of estrogen loss and what you’re seeing with cardiovascular health in the long run, the outcome there.

Dr. Carol Kuhle: We’ll see with menopause, with lack of estrogen, that there can be a change in lipid profiles. We’ll see more hyperlipidemia in these patients. Lipids are going to change. Risk for cardiovascular events goes up as women age. The important thing of working in primary care, to make sure their blood pressure is well controlled, their lipids are controlled. All those cardiovascular risk factors become really important in healthy aging later.

Dr. Christina Chen:  What I’m hearing is that as we age and we lose estrogen, it’s adding overall to our cardiovascular risk due to the elevation of lipid levels. We really need to focus on other healthy living aspects such as our diet and our lifestyle and all these other things, knowing that as a whole these will reduce our cardiovascular risk.

Dr. Carol Kuhle: Right.

Dr. Christina Chen:  Let’s talk about these lifestyle changes. We see a lot of literature nowadays on muscle health and strength training. Can that help?

Dr. Carol Kuhle: We really encourage women to exercise. I mean, every study that you see for healthy aging is on the top of the list.

Dr. Christina Chen: Exercise. It’s been our common theme.

Dr. Carol Kuhle: We know that muscle mass and bone health itself becomes really important as you age. Honestly, if a woman has not been on hormone therapy as they’ve gone through menopause, we’ll check a bone mineral density.

They are amazed that they have had some bone loss. Because as you age, from age 30 you start to lose bone. Then when you go through menopause and you stop having estrogen, there can be this precipitous loss.

That’s a concern if we miss that, they’re at risk for osteoporosis. But if they have osteopenia, that alone is an indication for hormone therapy. Even if they’re not having vasomotor symptoms.

Dr. Christina Chen: Osteopenia is the loss of bone integrity – not quite to the level of osteoporosis – but the bones are just less dense than they used to be, and more brittle to begin with. Going back to what you just said, how can you tell the difference between who absolutely needs hormone therapy versus those who might benefit from it, but doesn’t necessarily need it, versus those who absolutely should not undergo it?

Dr. Carol Kuhle: When we sit down with a patient, we look primarily at their breast cancer risk and their cardiovascular risk. Then looking at do they have active atherosclerosis disease?

Dr. Christina Chen: That’s when there’s a hardening of the blood vessel walls due to cholesterol and calcium buildup.

Dr. Carol Kuhle: Right. Depending on what that burden is, yes. At the time, then we may say, maybe you’re not a candidate. But for most women who are going through menopause, if we can capture them and they don’t have an elevated breast cancer risk and they don’t have an elevated atherosclerosis risk and they’re having vasomotor symptoms, we can treat them and they can feel so much better.

Dr. Christina Chen: I have seen that actually more often because over the past 10 years of practice, we’ve moved from hormone therapy to not so great.

Dr. Carol Kuhle: Yeah, exactly.

Dr. Christina Chen: We’re now more appreciative. The value of it, and understanding the risks a little bit more and understanding what myths have been debunked, right?

Dr. Carol Kuhle: Yeah.

Dr. Christina Chen: Let’s talk about sex now. How do you help people understand this is important to talk about? How do we help patients be more open and empowered to talk about menopause, sexual health and so forth?

Dr. Carol Kuhle: Changing the narrative is really important about how you neutralize the conversation and not make it a sexual health talk. It’s like, how’s your heart? How’s your bones? How’s your sex life? Introduce things that can happen. I mean, we know that 60, 70 percent of women are going to have one chronic disease. After 80, 90 percent are going to have at least one chronic disease.

Those chronic diseases and the medications that they’re on can impact their sexual health. Having that conversation of when women have diabetes, sometimes they have sexual health issues. Are you having any problems? How do you weave that into the conversation? Just neutralize it as this happens. How can I help you? Or I know where to send you if you’re having a problem.

Dr. Christina Chen: I like that. Just making it more of a natural “yes” question off of another question. Is sexual health always going to eventually change with aging and time and what’s considered that normal variation?

Dr. Carol Kuhle: Number one there’s no normal, and I tell patients that there’s no rules about sex. We know primarily the effect on the vagina and the vulva from lack of estrogen is a huge issue in sexual health because women will come in with low libido and I’ll say, well, are you having discomfort? Are you having pain during sex?

Well, yes. I’m like, why would you wanna have sex if it hurts? Treating the vulva with topical estrogen is awesome. It really helps patients feel comfortable. Oftentimes it’s not just the vulva, it’s also the whole pelvic floor that gets tight.

We have fantastic pelvic floor physical therapists that work with our patients. It’s that combination and then we bring them back and, okay, let’s have a conversation now. How is it going? Oh, yeah, that’s great. You know, things improve.

I mean, we talk about vibrators and we try to neutralize that. I just had a patient today who was like, “I don’t know that I’m comfortable.” By the time she left, she was like, “Oh yeah, I’m going to buy a vibrator. Because it’s not just for sex. I mean vibrators increase blood flow to the tissues. It makes them healthier. It’s all about vaginal health.

Because as women age and they don’t have estrogen, orgasm is a neurovascular event and if you don’t have good blood supply and you don’t have good neurologic supply things just don’t work like they used to. Topical estrogen actually helps with the blood flow and with sensitivity. The vibrator enhances that.

Dr. Christina Chen: You talked about vaginal dryness, decreased libido, painful intercourse. Does this happen around the perimenopausal period or does it happen much later, like decades afterwards where you’ve lost estrogen for a period of time? When do we typically see that?

Dr. Carol Kuhle: We can see that early on. Sometimes that’s what they come in with, the vaginal dryness issue and maybe not having hot flashes at all. It’s because they were in that group that didn’t have a lot of hot flashes, but they still lost the estrogen from the vulva and the vagina area. But the other thing they come in with is recurring UTIs.

When those tissues thin out, it’s very easy for bacteria to go from the rectum. There have been studies that if you treat it with topical estrogen, they go away.

I mean, I will start topical estrogen on women in their 90’s because they’re getting bladder infections. I explained to them, you’re at risk for urosepsis when you have that bacteria sitting in your bladder and they take that back and go, “Oh yeah, I really do need to do this treatment.”

Dr. Christina Chen: Yep. It’s a miracle drug.

Dr. Carol Kuhle: It’s a miracle drug. It is.

Dr. Christina Chen: How else can women maintain sexual wellness and intimacy after menopause?

Dr. Carol Kuhle: Libido is probably one of the other top conversations that we have with patients. So many women say, “I just don’t, I don’t care. I’m just not interested.” We have a really nice process that we take them through. First we look at, okay, what’s happening when you’re having sexual activity?

Do you lubricate? Do you feel aroused? Are you able to have an orgasm or not? Because there’s two different kinds of libido and we try to help women reframe what libido really is.

There’s that spontaneous libido that we have when we’re young and we have new relationships. But that over time does fade when you’re in a long-term relationship. We try to get at, how are they functioning? Someone will say, “Oh yeah, it’s great when we do spend time together, but I just otherwise don’t care.”

I said, “Okay, but this is when you’re just willing to participate in this and it works. so it works, right? Then we look at what are the medical, physiologic issues that women have? Do they have cancer? Do they have a neurologic disease? What are the chronic diseases that are playing a role?

What are the medications that they’re on that are playing a role? Then the hormonal piece is huge because clearly testosterone and estrogen are drivers for libido. But then we look at the psychosocial things like, “Do you have anxiety? Do you have depression?”

We pick up a lot of people that are like, “Yeah, maybe I drink a little too much alcohol.” Which will clearly put you to sleep and will decrease your ability to have an orgasm. Then we talk about what’s happening in the relationship.

If they’re really struggling in their relationship, it’s really going to be hard for them to wanna have sexual activity. Then the cultural piece, what did you learn growing up? What was part of their cultural background that’s playing a role in their beliefs about sexual health?

We’ll have a lot of people say we weren’t supposed to talk about sex. Don’t get pregnant before you’re married. All of those things play a role. I have a nice little handout and they’ll go, “Oh yeah, that one and that one,” so they can self-identify what the barriers are to their libido. And then we can kind of work from there.

I mean, we have a sex therapist that works with our patients, which is beautiful. We have our pelvic floor physical therapists that work with our patients and our nurses are so awesome because they can do all this nurse education on how you use the topical estrogen, how do you apply the patch?

What’s bone health? Yeah, we’ve got quite the multidisciplinary clinic when we’re assessing sexual health and libido. I just say to them, “Is it causing distress? Is it causing distress in you? Is it causing distress in your partner? Is it causing distress in the relationship?” If the answer’s no, I’m like, “It’s a non-issue. You’re fine.

There are plenty of people that are in their elderly years or not even that old, that just really enjoy their time together. Sex is not on their priority list. It’s okay.

Dr. Christina Chen: I am just thinking of the numerous times I’ve seen my older adult couples in their 90’s come to my office and they’re just like, “Oh, we haven’t had sexual activity in like 15 years. Variable reasons between. I just don’t have the energy, my hip hurts and all that. Absolutely. I’m glad to know that we don’t have to send them to women’s health.

Dr. Carol Kuhle: It’s okay.

Dr. Christina Chen: That’s a really good way to approach it. Because I feel like when they come to me with this question, I feel like I need to solve it. It’s like, do you want to? I haven’t even really asked them, are you content with your current relationship? Does it need to be?

Dr. Carol Kuhle: What are your goals? Right. What are your goals here? If their goals are, “I don’t know, I’m just fine,” I’m like, “Good. That’s all you need.

Dr. Christina Chen:  Another question as far as symptom management that I often get is about the supplements out there. Are there any non-hormonal supplements good for menopausal symptom relief or for sexual dysfunction? Do they even work?

Dr. Carol Kuhle: I mean, when we look at what is recommended and what is not recommended. Supplements are not on the recommended list. Okay. Only because there’s not good data that supports any of the supplements that are out there. We encourage more organic products, for lubricants and vaginal moisturizers. There’s a lot out there and there’s a lot of unknown out there.

Dr. Christina Chen:  What’s the consensus on soy products? Consuming soy milk, tofu, etcetera? Because people are still buying these products, consuming these products, thinking it can help with estrogen levels in the body, like a natural estrogen supplement of some sorts.

Dr. Carol Kuhle: There is a new product called Equelle. The whole idea is that soy products are metabolized to Equelle. Not everybody metabolizes them. Asians metabolize more. There’s been some small studies that looked at, does it help with vasomotor symptoms? Right now that’s one on the market that we’re still not sure about, but so far we haven’t seen any harm with it. Sometimes we’ll say you can give it a try and see if it makes a difference or not. But we don’t know long term.

Dr. Christina Chen:   Dr. Kuhle, what you’re saying is that the supplement, when it breaks down into a soy estrogen equivalent, can help with vasomotor symptoms or other symptoms related to menopause. Are there any other new or emerging treatments out there that are going to be on the market soon or under research? Anything innovative to look forward to?

Dr. Carol Kuhle: We were very happy about when Veozah got FDA approved. That’s the brand name for fezolinetant. It’s a medication for when you have vasomotor symptoms. There’s a process in the brain. The hypothalamus will have neuromediators that will turn on the hot flash. Estrogen turns it off, is how we explain it to patients. This medication turns it off, but it’s non-hormonal.

Dr. Christina Chen: Okay.

Dr. Carol Kuhle: There’s a lot of promise with that medication. There was a signal from the FDA looking at liver function tests though. We have to follow those to make sure they’re not elevated along the way, but that’s a new one.

The problem is anytime there’s a new product, it’s very expensive. There are coupons and ways to get around it, and insurance companies are starting to prescribe it and pay for it, but sometimes we have to do prior authorizations.

Dr. Christina Chen:  That’s really neat to hear about a new non-estrogen-based treatment that’s available where women can have other options to choose from now. I feel like the current solutions are not for everyone and there’s risk factors associated with long-term estrogen replacement, or perhaps treatments currently are not as effective, versus this may be more effective.

Dr. Carol Kuhle: More to come with that.

Dr. Christina Chen:   Are there any tools or resources both clinicians and patients can tap into, to help with the whole treatment journey?

Dr. Carol Kuhle: The Menopause Society is a fabulous resource. If you become a member of the Menopause Society, there’s actually a website you can go to. We use their handouts with our patients. Within the website, there’s also a provider list. What we’ve been doing is when we see a patient and we do a consultation and we wanna help them get local support, we have them go to that website and open up the provider list. Those are people who are certified in menopause. They can find people in their area that are certified and know how to help them continue to navigate this.

Dr. Christina Chen:   How would you encourage women to advocate for their health and to ask early, because sometimes treatment early is going to be the most valuable?

Dr. Carol Kuhle: I look at menopause as a bridge. If women understand that this is a really important bridge that they need to cross, what happens during that time is really going to play a role like we talked about as they age — in their bone health and being active and doing all the things that they want to do when they retire. We want them to get there. That was my interest in doing preventive medicine, because I know all about this. How do I help this group get here, in a better place?

From that standpoint, being knowledgeable as much as they can, there’s a book that we wrote, and Dr. Fabian is the editor, called The New Rules of Menopause.

It’s a great resource for women to look at everything that happens and the new knowledge that we have about hormone therapy and the safety profile of it. That’s really helpful. But I think providers need to know that women want you to ask. Women are out there on Google learning all kinds of things that maybe really aren’t the right information. They want the doctor to be proactive and ask the questions.

Dr. Christina Chen: Well, I have one last question for you, and this is a tradition we have on our podcast here: what does aging forward mean to you?  How do you personally like to age well?

Dr. Carol Kuhle: Well, what is the quality of life? That’s the thing that you’re looking at. What are the important values to you that will help you maintain that quality of life? If sexual life is important, that’s a quality of life issue — if sleep is a quality of life issue — I see exercise as really important.

Relationships are really important in navigating that. I hear so many women talk about the hardships of their families, things that are going on. For me, it’s how do I have relationships? I’m lucky I’m up in the cities. We have six grandchildren around us. That’s really an important part of my life. With my husband who’s a wonderful man. The other comment I wanted to make to women was that you are an untapped resource.

If you think about it, as you age, you have knowledge, you have experience, you have wisdom that you bring to the table. You can’t put that on a shelf. I hate to see anybody put a barrier on what contribution women can make as they age.

Dr. Christina Chen: That’s so true. With time, you gain experience, you gain more wisdom, you just gain more understanding of your value in life. That is powerful. Well, thank you so much for this conversation.

Dr. Carol Kuhle: Yeah, you’re welcome. It was actually a really fun conversation.

Dr. Christina Chen:  Yeah. Just having more comfortable discussions about this topic is so important, and to empower everyone who’s listening to not be afraid to bring it up because we all go through this at some point.

Dr. Carol Kuhle: Yeah, exactly. It’s inevitable.

Dr. Christina Chen: Thank you for being here today.

Dr. Carol Kuhle: You’re welcome.

Dr. Christina Chen: That’s all for this episode. Hopefully you’re feeling a little more informed, inspired, and empowered.

On the next episode of “Aging Forward,” “Care Transitions” — how to make the transition from one healthcare provider to another, from the hospital to rehab, or from the nursing home, back to your home safely:

Dr. Maria Mendoza De la Garza: The hospital teams are always taking care of a lot of patients that are really sick and ill. From the other side, working on the skilled nursing facilities and the rehabilitation center and the nursing homes, we are trying to understand what happened in the hospital. That’s one of the barriers we can see.

 For more information about the book mentioned in this episode, the New Rules of Menopause: a Mayo Clinic Guide to Perimenopause and Beyond, check out our show notes. If you have a topic suggestion for a future episode, you can leave us a voicemail at (507) 538-6272. We might even feature your voice on the show!  For more “Aging Forward” episodes and resources, head to mayoclinic.org/agingforward. If you found this show helpful, please subscribe, and make sure to rate and review us on your podcast app. It really helps others find our show. Thanks for listening, and until next time, stay curious a

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