A patient’s relationship with their gynecologist changes over time. “When one is younger, they might go to the gynecologist for birth control and to avoid an STD,” said Becky Lynn, MD, a gynecologist board certified in obesity medicine who runs her own practice and specializes in menopause and sexual health. “Then, during the reproductive period, one may be having babies, so they’re seeing their ob/gyn. But then having babies comes to an end, and there's this period of time where patients ask themselves, ‘Do I really have to [keep going]?’” According to Dr. Lynn, the answer is yes, but more importantly, physicians should spend more time considering the unique needs of patients during their post reproductive period, and educating and preparing them for the changes they may experience physically, mentally, emotionally, and sexually.
“Sexual health is health,” Dr. Lynn added. “I love providing this kind of care because patients sometimes say, ‘I didn't even know there was a doctor for this,’ or ‘I didn't realize that other women are having the same issue that I'm having.’”
A lot of patients are educating themselves online and then seeking care out of desperation or frustration with their symptoms, said Laura Streicher, MD, another gynecologist known for her research and publications surrounding sexual medicine and menopause. She revealed that most of the patients she has seen were actually self-referred. They came because they had read her book, heard a podcast, or seen something on TV about what they were experiencing. When these patients arrive, they may have incorrectly self-diagnosed or been ill-informed from taking advice from websites and consults that lack medical accuracy. “There is so much bad misinformation on the internet, especially about hormone therapy,” Dr. Lynn said. “I spend time with each patient explaining the misinformation about hormones on the internet.”
Besides the health misinformation online, some patients may be misinformed about what kind of care is covered by insurance, which specialist they should see, and what that specialist can provide. “Once patients are past their reproductive years, most people, assuming they have insurance, get one wellness visit a year,” Dr. Streicher said. “So if you're 50 years old and you don't have any gynecologic problems [that you're aware of], who are you going to see, your gynecologist or your internist? You're going to see your internist.”
Dr. Streicher said that the potential problem with the decision to eschew ob/gyn care is that the American College of Physicians says that women don't need a pelvic exam, which means that for internists, “below the belly buttons are a no-fly zone.” For a patient experiencing painful sex due to menopause or as a symptom of chemotherapy, seeing an internist instead of a gynecologist affects the exam they are able to receive and ultimately their diagnosis. Dr. Lynn also acknowledged the importance of older women getting an annual gynecologist exam: “Even if they don't need a pap smear each visit, it's important to come and get a pelvic exam and a breast exam and to have your blood pressure checked.”
The clinical encounter with menopausal and postmenopausal patients reveals a generational gap regarding the open discussion of sexual health topics. “When it comes to age ranges, it seems easier for younger women to talk about sexuality than it is for older women,” Dr. Lynn said. “I see a big difference. When it comes to something like a pelvic exam, most that have had babies are used to that. They've done it before.”
“But the older generations just didn't talk about [sex]. It was taboo. It was hush hush. Nobody really talks about menopause or female sexuality,” she added. To help facilitate conversations with her older patients who may not yet be comfortable discussing their sexual health in detail or feel they lack the vocabulary, Dr. Lynn provides an intake questionnaire that incorporates inclusive and open-ended questions. The questionnaire provides the patient with a way to communicate what’s going on if they aren’t ready to say it out loud and indirectly assures them that the symptoms that may have embarrassed them or made them feel alone are actually quite common.
“Many times people are experiencing sexual dysfunction but they’re thinking, ‘Oh my God, what's wrong with me? I'm the only person who has low libido. I'm the only person who has painful sex.’ Because no one talks about it,” Dr. Lynn said. “The people talking about their sex lives are happy with their sex life.”
An example of a case that Dr. Lynn has seen is a patient going through menopause and having their estrogen levels drastically drop, affecting the vagina and vulva: “Before menopause, the vaginal tissue is thick and moist. It makes its own lubrication. It stretches. Postmenopausally, it doesn't stretch, it doesn't self lubricate the way it used to. Sex can become painful, but many patients with female genitalia have no idea that it's related to a lack of estrogen. They're thinking, ‘Why am I not getting wet?’ And their partner might say, ‘Are you not aroused?’”
This patient may feel shame from not appearing physically aroused, but Dr. Lynn stressed that’s a normal physiologic change of menopause. This is why Dr. Lynn emphasizes the importance of physicians preparing their patients for physical changes in advance so that they don’t feel odd or ashamed of their symptoms, the same way patients are prepared for the physical change of puberty, periods, or pregnancy.
“Periods go haywire, hot flash with night sweats, sleep problems, weight gain, all of those symptoms — they're menopausal symptoms, but they actually start in the perimenopause or those several years before your periods go away,” she said. “So it’s really important as the physician to say, ‘Here's what to expect.’ We don't do a good job at educating or preparing women for what could happen down the line.”
There are also unique life stressors among patients who are menopausal or postmenopausal that should be taken into consideration. Dr. Lynn shared, “Around menopause is when kids might be moving away to college. Maybe [a patient’s] identity was in being a parent and caring for their kids. It can be very stressful and depressing to be an empty nester all at once. This age range might also be taking care of ill parents while still working. So maybe your kids are leaving, you've got a full-time job, your parents are ill or aging and need assistance, and then you add hormonal fluctuation on top of everything.”
Patients past their reproductive period still need gynecologic health care. That is a time when many body changes and life changes may be occurring simultaneously and clinicians have an opportunity to ease that transition through support and education on what to expect and how to best prepare healthwise. “We get a very good education when we're younger on how not to get pregnant and how not to get a sexually transmitted disease, which is important,” Dr. Lynn said. “But women's needs change as we age.”
Illustration by Alphavector / Shutterstock
