“I hate him!” said my patient. ” Don’t look at me like that Mr. Akhan, I really hate him. Also, didn’t you remove my ovaries during the surgery? How does this happen then?”
When I looked at her with doubt, I have seen expressions on her face which can be seen at the faces of people who are angry and confused and people who cannot apprehend. She continued; “I mean, how is it that I want to touch him and want him to hug me? I want to know where he is and who is he with and when he doesn’t call me I get angry like I am a teenage girl? And with him (a short sigh) well, you know!”
In a meeting I attended in 2012, a colleague there asked me: “When does sexuality begin and end for mankind?”
“It starts in the womb and ends with death” I answered.
It is perfectly explained in a compilation written by Helen Kaplan in 1991: “As long as Men and Women are healthy and have adequate partners, they stay sexually active until the end of their lives.”
What surprises my patient is that the emotional situation and reignited sexual interest she has, on top of being 55 years old while having these emotions. But main reason of the emotional confusions she is in are not just local sexual dogmas etched in our heads but effective throughout the world.
Two terms that are considered as taboos in many cultures are menopause and woman sexuality. On the contrary, the well-known expression is: “Passion is an obstacle on path to wisdom while aging.” (A fancy sentence that I have borrowed from a book, if I have remembered it correctly.)
To talk about sexuality for a woman who is mother and/or a grandmother, or to show interest for someone is considered “shameful.” Whereas in literature, “negotiating sexuality” which can be described as “sharing and talking about sex”, is vital for a woman who is in her menopause era.
While woman is afraid of controlling these physical and psychosexual excitations due to sexuality in this period, the ambition for sexual experience she wants to have brings the risk of social rejection with it. Expressions such as “Really?! In this age?!” can be unbearable for a woman in such male-dominant world.
By the way, primarily the visual media always imposes the myth; “Only the young and beautiful woman deserves sexual activity!” Especially if a woman is in menopause! Please pay attention to the “no spring chicken” woman types in recent TV series. All of them are appearing as “mature” and “asexual” woman.
Yes, yes, I know, your mom and dad never touched each other, they always played tag, you were brought by storks and actually some of you were found at a cabbage field. You are aware that we are fooling ourselves with these fables right? Just know that they are still playing tag with each other.
Do not think that only you have this perception. Sexual subjects for doctor, especially in menopause era, are seriously ignored subjects by us. All in all we are also shaped by the perceptions of the culture we grew up with.
During my chief assistant and associate professor years, because I was actively making assistants have the surgeries, occasionally they were scolded by me. As you may have guessed, the topic of these scolding can vary between patients and surgeries that were being made. The most important scolding matter before the surgeries of patients who have uterus and bladder prolapse were about sexual activity.
These surgeries are made frequently to the patients who are in menopause and since removing the uterus is chosen as a surgery technique we somewhat contract that area. But the degree of this “contraction” process closely depends on the fact if the woman is sexually active or not. Because if you contract excessively, not before three to five months the husband finds you and questions: “What have you done, doctor?”
Getting rid of the dogmas inside the assistants’ head takes a long time. Nevermind, They cannot even imagine 50-55, even 60 or 70 year old ladies can have sexually active lives. Because they have lived to the “ripe old age!”
But I always force them to ask and I have always loved the shocked expressions they get when they are answered otherwise and from that point on, they never forget to ask those questions.
The reason we believe in some myths about sexuality is because, sexuality is perceived simply “shameful” in almost all of the societies throughout the world.
On the contrary, the concept of sexuality is a multi-sided process which has; psychological, biological, moral and cultural parts. This process is a motion that continues throughout life and it is formed and developed as a result of one’s lifetime experience, self identity, relations and privacy.
Some changes emerge for a woman who is in menopause, which I don’t want to mention thoroughly but are very important. These alterations can be specified under three categories:
1. Physical Alterations: Symptoms such as central/male type adiposity (this is the reason why a woman in her menopause period should do sports and take care of her diet); reducing levels of collagens and looking “aged” especially over facial areas (and this is why you have to quit smoking); hot flashes, excess sweating; “draught” which effect sexual activity in woman directly, losing control of bladder.
2. Psychological Alterations: Emotional condition changes where specifically, depression can be observed; “Empty home syndrome” which can intensify with the moving out of the children because of education or marriage. Woman feels alone and unhappy.
3. Cognitive Alterations: Loss of attention, or problem caused by short-term memory loss; problems that come with having a hard time learning things, “not understanding and not comprehending” complaints are often. My patients who are mathematics teachers complain about “not being able to solve pool problems.” My suggestion is that you should do plenty of crosswords or Sudoku. They are good for your cognitive functions.
The alterations listed under these 3 main topics which occur to women during menopausal period can cause loss of self-confidence and will directly affect sexuality negatively. But the most important point is that the damage which is done to the woman’s body image during these changes.
Body image is an intellectual and/or spiritual “structure” which continuously and dynamically shapes itself throughout the life with the effect of psychological and neurologic processes.
Throughout the life, every neurobiological, psychological process can change the perception of the body image of oneself. Body image is one of the key aspects of sexual identity.
Physical, emotional relation and its quality and importance one experiences during sexual activity, having a direct effect on their body image, also body image can effect and change sexual functioning and response.
Physical and mental alterations taking part in menopausal period negatively effects this perception and causes loss of self-confidence in woman.
My fellow males’ negative statements and actions increases this bad perception. Especially undereducated woman who are forced the “mother” role, are accepting this “motherhood/grandmotherhood” role in their social environment and identifying themselves as an “asexual” body image.
On the other hand on a geography where “manhood” is never questioned, the sexual problems of men directly affect woman’s sexuality but very few of these men choose to consult a doctor for a treatment.
Methods we prefer are, second-hand knowledge gained from chatting with friends and products we come across via Google. But these methods are far from becoming a remedy.
Sexual problems of men directly affect woman’s sexuality, and know this, type of news such as “Helga loved all of her men”, are subconscious tickling attempts of colored media with the purpose of getting more rating.
The rate of erectile dysfunction in Turkey with men over 40 years old is 70% (http://arsiv.ntvmsnbc.com/news/103149.asp). Just like dear Prof. Dr. Ateş Kadıoğlu, who made the statements in the news, has told me “One day you will wake up Süleyman, and nothing will be the same.”
Therefore the education level of man and woman and the sexual dysfunctions of man directly effects sexuality of a woman who is in her menopausal period.
In academic regards, this claim is based on large-scale researches such as SWAN. Results of many different tests show that, as the education level increases, woman’s perception of sexuality, her pleasure and other sexual functions are positively affected.
Especially the results acquired from the tests applied to high school and university graduates are clearly higher compared to other women.
It is necessary to mention the results of multi-central CLOSER study conducted by Nappi et al. The study published in 2013, is a study evaluating the effect of dryness that occurs after menopause on the woman and her husband.
One of the shocking results of the study was that dryness affects the relation in sexuality very badly if the husband concurrently has erection problems.
Again in Spain, MARIA study published in 2012 including 179 sexually active women aged 40-65 showed positive correlation in peri and post menopausal woman’s and her husband’s educational level and sexuality scores while concurrent erection problem showed negative correlation.
Turkish data showed an increase in human life similar to the entire world. Approximate female life rates are 73.4 in 2003, 73.8 in 2005, 74.2 in 2007, 75.8 in 2008 and 76.1 in 2009.
Therefore, women’s menopausal life period is extended and will keep on extending. Today, life expectation of northern Scandinavian countries is around 90. There is a similar case in Turkey.
One of the basic numbers that do not change in woman’s life cycle is the age of menopause. While the age of first menopause is reducing (we should discuss that some other time), the age of menopause does not change and it is around 50. With another point of view, the duration spent in menopause is approximately 26 years for our country according to 2009 data!
As a result, this increasing period is a period that requires taking precautions for keeping the life quality, thus reconsidering the priorities without getting away from the facts too much ( not visiting plastic surgeons too much) in order to adapt to life in many other points.
In this process, woman’s sexuality is an inseparable part of a qualified life. It is possible to provide different solutions to women who consult doctors with sexual problems.
However, while looking for solutions to those who consult the gynecologist due to sexual function disorders, all the factors should be considered, husband should also be evaluated, other disciplines should be consulted when necessary and a totalitarian approach should be take due to the excessiveness of factors and the changing nature of the sexuality.
Although I do not agree with Freud’s all statements, I like his saying “Sexuality is the last and only toy left for adults”.
You should protect your only toy
With love, and respect
Glad to have you
Note: What would you advise to my patient I told at the introduction?
1. Castellanos-Torres E, Álvarez-Dardet C, Ruiz-Muñoz D, Pérez G. Social determinants of sexual satisfaction in Spain considered from the gender perspective. Ann. Epidemiol. 2013;23(3):150-156.
2. Pelusi J. Sexuality and body image. Research on breast cancer survivors documents altered body image and sexuality. Am. J. Nurs. 2006; 106: 32-38.
3. Kundakovic M, Gudsnuk K, Franks B, Madrid J, Miller RL, Perera FP, Champagne FA. Sex-specific epigenetic disruption and behavioral changes following low-dose in utero bisphenol A exposure. Proc. Natl. Acad. Sci U S A. 2013; 110(24):9956-9961.
5. Sternfeld B, Guthrie KA, Ensrud KE, Lacroix AZ. et al. Efficacy of exercise for menopausal symptoms: a randomized controlled trial. Menopause. 2013; 12.
6. Wood JM, Mansfield PK, Koch PB. Negotiating sexual agency: postmenopausal women’s meaning and experience of sexual desire. Qual Health Res. 2007;17(2):189-200.
7. Dennerstein L, Randolph J, Taffe J, Dudley E, Burger H. Hormones, mood, sexuality, and the menopausal transition. Fertil Steril. 2002 ; 77:42-48.
8. Cain V.S., Johannes C.B., Avis N.E., Mohr B., Schocken M., Skurnick J., Ory M. Sexual functioning and practices in a multi-ethnic study of midlife women: baseline results from SWAN. J. Sex. Res. 2003; 40: 266-276.
9. Pérez-López FR, Fernández-Alonso AM, Trabalón-Pastor M, Vara C, Chedraui P; MenopAuse RIsk Assessment (MARIA) Research Group. Assessment of sexual function and related factors in mid-aged sexually active Spanish women with the six-item Female Sex Function Index. Menopause. 2012; 19:1224-1230.
10. Nappi RE, Kingsberg S, Maamari R, Simon J. The CLOSER (CLarifying Vaginal Atrophy’s Impact On SEx and Relationships) survey: implications of vaginal discomfort in postmenopausal women and in male partners. J Sex Med. 2013; 10: 2232-2241
11. Aziz A., Brännström M., Bergquist C., Silfverstolpe G. Perimenopausal androgen decline after oophorectomy does not influence sexuality or psychological well-being. Fertil Steril. 2005; 83: 1021-1028.