Unveiling the pleasure of sex during menopause – a tale of two ‘disruptive’ sexual health practitioners

If sex is stigmatised, menopausal sex is a total taboo. Two of the most talked about presentations at the recent SA Menopause Society Conference in Stellenbosch involved sexuality during menopause. One of these presentations was by Dr Elna Rudolph, a sexologist and President of the World Association of Sexual Health, who stressed the importance of focusing on pleasure when discussing sexual health with menopausal women. Pleasure, Rudolph argued, is an essential aspect of sexual health that should be addressed in healthcare services, despite being a sensitive and stigmatised topic. In a refreshingly balanced fashion, the second of these presentations, delivered by Cape Town-based sexual health practitioner Dr Paul Abramowitz, was primarily aimed at educating men about the importance of intimacy and mindfulness when dealing with menopause and sexual health. Veteran health journalist Chris Bateman covers the complexity of this critical subject in this two-part article outlining the ways in which both Dr Rudolph and Dr Abramowitz are disrupting the way many colleagues think about sexual health generally. These stories first appeared in Medbrief Africa/Axess Health. – Nadya Swart

Towards pleasurable menopausal sex

Physicians discussing sexual health with menopausal women should focus on pleasure, not function – and work with a team to facilitate this.

That was the core message from Stellenbosch sexologist and President of the World Association of Sexual Health, Dr Elna Rudolph, to an audience of mainly gynaecologists and obstetricians at the SA Menopause Society Conference (SAMS) in Stellenbosch last week.

She urged her audience to ‘appropriately and professionally’ prepare themselves for sexual health consultations and perhaps take a cyber course in sexual attitude reassessment to avoid being ‘thrown’ by unexpected menopausal presentations. These could include an elderly-women with a penis, a swinger, or a patient who was polyamorous or practising ethical polygamy.

“Sex is political. My primary concern is that the plight of women is not in the conversation,” she asserted.

Rudolph asked the conference, “How can we enable menopausal women to have sex? There are 256 reasons for women to have sex. Some to pleasure, some to control and some to manipulate – but pleasure is a very good reason!”

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International comparative research consistently showed that diverse forms of sexual pleasure improved both individual happiness and overall health as well as the quality of relationships – which could contribute to the health and well-being of individuals, couples, families and communities.

Urging “ethical curiosity” by physicians, she advised them to diplomatically ask their patients whether they were sexually active (with themselves or with other people) and, if not, whether this was by choice. If not by choice, this then opened the door to ask for permission to discuss and, if denied, reassurance that they were always welcome to discuss any sexual health concern.

If a patient confirmed being sexually active, the physician should ask whether they were experiencing any problems with sex or pleasure that they might want to discuss. If they were not or did not want to share, the reassurance for future discussion pertained. If they were having problems, the invitation to discuss could be safely made – or a referral offered.

Alternatively, physicians could assess for hypo-active sexual desire disorder (desire discrepancies versus “low libido”), arousal disorders, orgasmic disorders, genito-urinary pelvic/penetration disorders, or out-of-control sexual behaviour such as paraphilias (persistent, recurrent sexual interests, urges, fantasies, or behaviours of marked intensity), addictions, gender-based violence or body dysmorphic disorder.

“Also, assess the enabling factors for sexual pleasure in your history taking – what is good for the heart is good for the clitoris – or penis,” she stressed.

Rudolph said a healthy lifestyle, avoiding smoking, controlling weight, exercising, a low-carb Mediterranean Diet, having fun, connecting, “training the brain”, and self-care were all vital enabling aspects.

So too, was taking a psychiatric history for diagnosis and medication, establishing the type of hormone therapy they were on and for what, plus all medical conditions which treatment was previously prescribed for.

Equally important enabling factors were the extent of self-determination, consent, safety, privacy, confidence, and the ability to both communicate and negotiate. Physicians needed to affirm the possible impact of menopause, medication, surgical procedures and medical conditions on their patient’s pleasure. Concerns need to be met with scientific evidence, rights-based and experience-informed information about sexual functioning and sexual pleasure. Brakes and accelerators in enjoying sex also needed to be discussed.

Read more: Sex and porn addiction: a critical, candid conversation with expert Dr Paula Hall and Remojo’s Jack Jenkins

When it came to products and devices for menopausal patients, Rudolph said silicone estrogen-based lubricants were “way superior” to water-based ones, while vibrators and vaginal dilators were frequently necessary. 

“For a woman to have sex, she needs to accommodate a size five dilator – some go up to size eight (medical grade) dilators,” she added.

She recommended reading “Come as you are” by Emily Nagoski and online courses such as “How to have more fun in Bed”, “Kink 101” by Lisa Welsh and “From pain to pleasure” by Candice Lanford, plus www.sexologycourses.com. Erotic literature plus ethical porn (Ericalust.com) would also help expand the erotic intensity of a patient’s sexual experiences.

She said Sensate Focus Therapy was a valuable tool, as was equipping patients with a vocabulary to enhance communication about sexual pleasure. Words like “harder, softer, faster, slower, up, down, left, right, deeper and stop” were some examples.

All chronic conditions should be managed optimally, but with drugs that have minimal sexual side effects.

“Where appropriate, offer medication that can address sexual dysfunction and enhance sexual pleasure – your patient has a right the enjoy the benefits of scientific progress,” Rudolph stressed.

She recommended Estradiol (especially vaginal), Tibolone and transdermal testosterone (which needed monitoring)

Asked who to refer for intensive therapy, Rudolph singled out patients with a history of sexual abuse, anyone with low scores on “any of the ‘pleasure meter’ parameters, or any patient you don’t feel comfortable or competent to help yourself,” – and anyone who asked about a referral.

“Sexual pleasure is best attained through facilitating access to the highest standard of health. Today global data show a persistent high burden of sexual health issues, yet pleasure remains a sensitive, stigmatised and unspoken topic in healthcare services,” she asserted.

She said physicians needed to realise that pleasure was “a fundamental reason why people have sex”. Acknowledging this would help create safer, more pleasurable sexual experiences.

Dr Elna Rudolph, MD, is President of the World Association for Sexual Health, Clinical Head of My Sexual Health, and runs sexology courses for healthcare providers.

A pause for men in dealing with menopause – Paul Abramowitz.

Cape Town-based sexual health practitioner, Dr Paul Abramowitz, steered the SA Menopause Society conference in Stellenbosch in a more fundamental direction – intimacy and mindfulness, focusing on “extraordinary sex” and debunking male sexual myths.

He invited his mostly obs/gynae audience to consider a “thrivesome” approach to both themselves and their patients in day-to day-clinical consultations, saying he’d witnessed the discomfort and pain people went through in dealing with menopause and sexual health generally.

Premising his talk on self-evolution, he said relational health with self and others could determine how well a physician and/or patient adopted the better-known wellness indices. Author of “SeXed – Hardwired by nature – Evolving by choice, a book for men and the women who love them”, Abramowitz told Medbrief Africa in a post-conference interview that at puberty, men and women were “invited onto the dance floor and held closely by the biological intelligence of the reproductive imperative”.

“Then suddenly, most of us are invited off the dance floor of the reproductive imperative – after many years of dancing in tune with our biology. My book speaks to how puberty impacts our adult male heterosexual brain via our introduction onto the reproductive dance floor. The conversation seeks to awaken men to another way of being sexual and intimate.”

When it came to menopause, reclaiming function, meaning and dignity in a transformative time of biological change could make all the difference. 

“It’s a predicament for heterosexual couples. Gay couples can often go through menopause together and find a more compassionate understanding. But for men and women, who often don’t have that shared biological understanding and who’ve had pretty well-trodden sexual paths, when the change comes, it can be difficult.” 

Well-being versus thriving.

He told delegates that well-being was a prerequisite for thriving – but thriving involved actively pursuing growth and fulfilment in all aspects of life.

Citing research, he said the absence of close relationships represented a health risk equal to or greater than health risks such as smoking, alcohol, BMI or lack of physical activity. This often came as a great surprise to many people, and too few doctors asked their patients about this when probing their general health.

“We can always do better at diminishing the impact of what keeps us separated from ourselves and others – and grow our capacity for meaningful relationships towards better outcomes,” he said.

Regarding physician stress, Abramowitz said healthcare professionals often faced life-and-death situations, including legal challenges, insurance and hospital politics which easily elicited feelings of stress, burnout and isolation. This made becoming -aware of their own hostility, ostracism, rejection and negativity and moving to recalibrate and “return to our centres” an essential tool in bringing forth the best in their human natures.

He said a robust Gallup poll from over 140 countries involving five million interviews showed that loneliness and isolation ranked just third behind food, money shortage and job dissatisfaction. From a biological perspective, social isolation and low social integration elevated blood pressure, lowered immune responses, increased pro-inflammatory cytokine production and slowed wound healing. On the endocrine front, greater cortisol reactivity led to faster ageing, impacted cognitive function and increased anxiety and depression. Poor physical health, cardiovascular disease, chronic pain and obesity were thus more likely. 

Greater social connection induced gratitude, love and belonging, all “thrivesome states” that protected health and promoted thriving environments.

MRI studies showed that practising mindfulness reduced judgement, stopped knee-jerk reactions, and allowed greater discernment and learnings from the past, plus increased understanding, compassion and “kindfulness” (his own terminology).

“Because our inner landscape determines how we interpret our outer one, having more jurisdiction over our inner world enables us to redefine our experiences and, indeed, our reality. Mastering our own area of jurisdiction to leverage our brain’s ability to rewire through neuroplasticity makes masterful sense,” he said.

Mindfulness literally “puts a lid over our amygdala. When we flip our lid, our reactive side shows up – not great for stress reduction or building relationships, so the practice of mindfulness keeps the reactive aspect of ourselves under wraps if you like,” he said.

 It was about “the finessing of our human expression and gathering up tools in order to be in our best relationship”.

The intelligence of intimacy

This led him to the final question of what he meant by “the intelligence of intimacy” and how key researchers had redefined the conversation on optimal and extraordinary sex. 

Citing findings by psychologist/sexologist Dr Peggy Kleinplatz of the Faculty of Medicine at the University of Ottawa, he said she had fundamentally challenged the status quo on “what great sex is”.

Kleinplatz interviewed hundreds of couples who claimed to have extraordinary sex and created 12 ranked indices, the top eight inviting participants more fully into their humanity.

The lesser four were lust, chemistry, intense physical sensation and orgasm.

The key indices for optimal sex were embodiment, focus, immersion, and extraordinary communication (verbal and non-verbal).

“She found that respondents who had experienced extraordinary sex saw it as an adventure of ongoing exploration and an opportunity to be authentic, uninhibited and totally free. They enjoyed vulnerability and described sex as ‘blissful, timeless, transformative and healing’,” he added.

Abramowitz said that with people seeking to reimagine their sexual experience, “getting there” involved growing a greater sexual intimacy quotient (his term) and agility of mind, sometimes helped on by mindful stretch movements. This allowed men, especially, to slow down and reframe old ways of having sex, particularly penetrative sex.

“They arrive in the therapy space with little understanding of their biological and emotional sexual hardwiring, and after some time, through gaining greater insight, they expand their intimacy quotient and begin to access the optimal Kleinplatz indices more easily.

Abramowitz said he found that showing men their own complexity helped them to meet their partners with more compassion and understanding, particularly at a time of extraordinary biological and emotional transformation – and to find a new level of mindfulness.

The tools he uses include sex cycle maps from his book through which men discover a mindful sexual awakening (beyond puberty and adolescence) and diminish the idea of sex as containing only the tendency/compulsion to ejaculate and/or lessen life’s stresses.

“When we’re able to change old ways of thinking about sex and intimacy as men, our entire lives can change for the better”, he concluded.

Dr Paul Abramowitz dedicates his professional life to both his medical practice as a periodontist and dental implant surgeon. He holds a PhD in Sexuality with a special interest in heterosexual relationships, love and intimacy.

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