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The changes that occur in the body during menopause can turn sex into torture, and explain how natural therapies can help rebalance the body and put back the pleasure.

Vaginal dryness

The change in hormones during perimenopause, menopause, and post menopause is a prime reason for vaginal dryness. This condition causes some discomfort during sex, or even before sex, resulting in soreness and sometimes a feeling that you may have cystitis, although you don’t. The dryness can lead to vaginal tearing, with or without sex. Obviously, this creates an aversion to sex, which will have an impact on sexual relationships with partners.

Dryness may also arise from pelvic radiation or chemotherapy, and of course is heightened in someone who is going through perimenopause or menopause while undergoing treatment for cancer. Certain medications can exert a drying effect on the vaginal tissue. It's important to mention this to your GP so they can check whether any medications they prescribe may be behind this. Other causes are allergies or sensitivities to soaps, tampons and materials worn close to the skin. Ideally, wear cotton underpants and avoid using inserted menstrual hygiene products.

Having no sex can also be a cause dryness, as can insufficient arousal, something that needs to be discussed with your partner, especially as the condition can be improved by regular sexual activity, whether alone or with a partner. The key is to increase the activity of the muscle in the vaginal walls, otherwise lubrication doesn't come through. The other aspect is that without this activity, the vaginal tissue can become tighter and smaller.

In terms of herbal remedies, I prescribe black cohosh and/or red clover. Because the effective dose is quite high, it’s important to consult a herbalist. Also, understand this is not a quick fix: the herbs need to be taken for a minimum of eight weeks before there's any possibility of change. With red clover, the evidence suggests it's at least 187 days before signs of improvement start to manifest. I also advise my patients to take fish oil for its omega-3 essential fatty acids EPA and DHA, at a minimum dose of one gram per day, along with vitamin E at 100 IU per day and vitamin A at 2500 IU per day. Additionally, ingest plenty of beta-carotene, which is found in orange vegetables and fruit, and green vegetables. So your diet should include lots of leafy greens, fish, nuts and seeds.

Vaginismus

An unpleasant and upsetting condition, although fortunately quite rare, vaginismus occurs when inserting any object – whether tampon, speculum or penis – into the vagina. This causes the involuntary contraction of the pelvic floor muscles, leading to an involuntary muscle spasm and a tightening of the vagina. The associated pain means women cannot use tampons, undergo gynaecological exams or have sex. Vaginismus requires a multi-modality approach because so many factors can be involved. I advise patients to speak to a counsellor or a psychotherapist, and possibly a hypnotherapist, as well as a natural therapist.

Generally, I recommend high levels of magnesium to relax the tissue – but no more than 800 milligrams of elemental magnesium per day because higher doses can cause a spasm. Don’t use magnesium oxides, as this form is likely to lead to diarrhoea at that dose. Eating magnesium-rich foods is also advised and again, leafy greens are the best source. Anti-anxiety herbs such as St John's Wort can be beneficial, but it’s important to consult a herbalist as this herb is contraindicated with so many medications taken as we get a bit older.

Lowered libido

So many women experience this. Essentially, it's about mismatched libido, or incompatibility of sexual desire where one partner desires more sexual activity than the other, giving rise to conflict. So, discussing the problem with your partner, changing sexual patterns or consulting a counsellor are very important, as well as dealing with the stress associated with the conflict, which can lower the libido even more. This, too, is a condition that requires a multi-modality approach.
With stress levels a major factor in a lowered libido, supporting the stress response is vital. And this means making sure there is plenty of time to be with a partner and plenty of space outside of work so that a woman can enjoy life a bit more and not regard sexual relations as being a chore.

The neurotransmitter noradrenaline affects nitric oxide and the vasoactive neuropeptides, which help balance the blood flow to the female reproductive area, an action regulated by oestrogen and testosterone. Natural therapists support oestrogen and testosterone in a female and help to reduce stress levels by suggesting mindfulness and counselling and possibly hypnotherapy. Random controlled trials suggest that red clover – again in a dose of 80 milligrams per day for at least 187 days – helps with libido, sleep and mood. Tribulus is another effective herb, but I will caution against the 20-gram doses currently being sold as they are far too high and can cause a woman to become more aggressive. The traditional dose for tribulus is about 750 milligrams, which I couple with a standardised extract of ginkgo as it helps to increase blood flow to the peripheral areas, including the vaginal tissue. In clinical trials this combination improved sexual arousal scores. It can be used in tandem with SSRI medications – and the reason I mention this is that women with lowered libido often take anti-depressants.

The other factor is exercise, the basis of which is improved blood flow, although it’s also about appreciating and loving your body. Some clinical trials suggest women who exercise – and particularly those who do weight training – retain a small amount of testosterone, which will improve libido.

Dry skin

Dry skin is a natural part of ageing: as oestrogen starts to decline, the factors that encourage the natural oil production also decline. Fish oil helps with skin dryness as it does with vaginal dryness, along with omega-6 seed oils. A study involving more than 4000 ageing women found higher levels of vitamin C intake combined with fish oils and omega-6 fatty acids resulted in less skin dryness, a less wrinkled appearance, and higher moisture and sebum production in the skin. So essentially the message is “oil from the inside to oil the outside”. But again, this is not a quick fix: you're looking at a minimum of three months.

Another study linked high carbohydrate and high saturated- and trans-fat intake with an increased likelihood of wrinkles and skin atrophy – and this was independent of race, education about diet, age, sun exposure and body fat. Consuming higher levels of protein and more fruit and vegetables are effective for reducing dry skin. Another study found argan oil ingested and applied topically for 60 days resulted in a statistically significant improvement in both skin elasticity and skin dryness. If you look at the composition of argan oil, this action is most likely due to its high level of antioxidants. The oil is also rich in vitamin E tocopherols, and we know higher levels of vitamin E down-regulate TGF beta, which encourages fibroblasts to grow more collagen and elastin fibres, thereby reducing dryness and increasing skin integrity. Also present in abundance are polyphenols, which are known to be anti-aging. This is especially true of ferulic acid, which stays in the bloodstream longer than any other antioxidant and helps prevent oxidative damage.

Hot flushes

Diminished oestrogen is the cause of hot flushes, which can occur three times a day, or 30, ranging in severity from a slight glow to debilitating sweats where the woman’s hair sticks to her head. They can occur during the day or night, or sometimes just at night.

In clinical trials, Pycnogenol taken over a six-month period at 200 milligrams a day has proven to be very successful. However, my personal favourite – and this is empirical and historical, rather than from an evidence base – is sage tea, which has been used for centuries. This herb is easy to grow and use: steep a teaspoon of dried sage in a cup of water three times a day and drink the tea. Sage is toxic in large doses, so when I say three teaspoons per day, this is the maximum. A very small open multi-centred trial found just three cups of tea a day reduced the symptoms of hot flushes and that nasty menopausal sweating.

Soy phytoestrogens have been given a very bad rap, with suggestions they cause or initiate cancer, and worsen breast and uterine cancer. However, 16 double-blind studies have found this is not the case. Phytoestrogens exert a very potent modulating effect on the highly active alpha oestrogen receptor, via the weaker and secondary beta oestrogen receptor. So the isoflavones act as a protector of breast and uterine oestrogen. An Austrian menopause study found soy isoflavones were 25 percent more effective than a placebo, and could mimic 57 percent of the potency of oestrogen. The Austrian Menopause Association suggests this should be the first line of therapy, above HRT. The dose of 80 to 120 milligrams a day is safe for women taking tamoxifen treatment for breast cancer who are suffering from hot flushes. Other isoflavones can be found in peanuts, chickpeas, alfalfa, broad beans and kudzu.

Exercise may be of benefit: the longitudinal Melbourne Women's Midlife Health Project, which followed 438 women for eight years, found those who exercised every day were, at baseline, 49 percent less likely to report hot flushes than those whose exercise levels decreased. So, a very good rap for exercise. The other recommendation is the appropriate removal of oestrone – a less favourable form of oestrogen – by supporting the liver. This involves reducing or eliminating alcohol; reducing coffee intake; increasing vegetables from the Brassica family, such as cauliflower, broccoli, bok choy, and Brussels sprouts; and using the herb St Mary's thistle.

Sleep disturbance

As we get older, our sleep becomes more disrupted, and we don't sleep as long. Sleep deprivation can make us feel more tired, impair cognition, promote weight gain, and cause depression and anxiety. So, making sure we stay asleep is a very important factor. Difficulty in getting off to sleep is generally associated with poor sleep hygiene. To improve this:
*Eat dinner before six pm so you’re not trying to go to sleep with a full stomach.
*Think relaxing thoughts, meditate, or listen to some good music.
*Make sure the room is completely dark.
*Some magnesium may help relax the body and mind before going to sleep.
*Switch off mobile devices – especially back-lit monitors – at least two hours before bed.
*Avoid anything stimulating – and this includes TV because although people claim it's relaxing, the reality is that it stimulates the brain and also enhances adrenaline, which doesn't help you to sleep.
 
The decrease in production of both oestrogen and progesterone is also a factor. Oestrogen regulates cortisol, which increases a little during perimenopause and menopause. Progesterone – an anti-anxiety hormone – regulates GABA. Therefore a decrease in oestrogen and progesterone means we're slightly more anxious and slightly more alert at night time. Natural melatonin will block arousal at night, but unfortunately production decreases with age as oestrogen supports the manufacture of melatonin. Your GP can prescribe melatonin supplements, or alternatively red clover in an 80-milligram dose over a period of 12 weeks supports and helps manufacture natural melatonin.
 
My other precursor for getting to sleep and having a good night’s sleep is to take plenty of exercise during the day. Ideally, work out first thing in the morning, to the point where you’re huffing and puffing. Yoga is very good, but it doesn't help with sleep as much as something like weight training, or high-intensity interval training (HIIT).
 
Teresa Mitchell-Paterson is an Australian Traditional-Medicine Society member, and holds a Bachelor Health Science (Complementary Sciences), Master Health Science (Human Nutrition), and Advanced Diploma Naturopathy.