Mrs Jones, a 55-year-old teacher, has been married for 30 years. She says she attends the practice because she feels tired and has gone off sex. She is postmenopausal and had hot flushes two years ago, but declined any treatment at the time. How would you manage her?
It is important to let patient feel that they can express how they feel without being judged
Opening the consultation
When opening the consultation, be careful not to jump to conclusions. An open, non-judgmental attitude is necessary to make patients feel safe and secure enough to express their innermost concerns and feelings.
Begin by asking Mrs Jones to give you an example of what she means by 'being tired' and how this is affecting her daily life and relationship with her husband. How long has she been experiencing these symptoms? Does she feel the symptoms are linked to any particular event at home or at work?
Next, ask her if she told her husband about the appointment, and what he would say if he was at the consultation with her.
Acknowledge her previous visit to the practice and ask her how she is coping with her menopausal symptoms. Find out when she last had a vaginal examination.
Mrs Jones tells you that by the end of the day, she feels completely exhausted and cannot even be bothered to prepare a meal; all she wants to do is go to bed and sleep. Her hot sweats still cause her to wake in the night. Now she often sleeps in the spare room, so her husband is not disturbed and they can manage their working day.
She also tells you about a conversation she has had with her husband, during which he mentioned that now their children have left home, they have some privacy and he would like to have regular sex.
Although she is happy that the children have left home, the house is quiet and her daily routine has altered. At the moment, sex is the last thing on her mind, but she is worried that if she does not sort out her tiredness, her marriage might be at risk.
Explain to the patient that many women experience difficulties during the menopause, an important stage in life that should not be ignored, even though it can be embarrassing to talk about it. Reassure her that she was right to attend the practice because her symptoms are causing considerable distress.
Ask Mrs Jones about when she and her husband last had intercourse and how intimate they are. Do they hug and caress one another? Do they spend time together socially?
Mrs Jones tells you that she last had intercourse eight months ago, and although she and her husband occasionally have a hug, she avoids being intimate because he might think she is giving him the green light to have sex.
Ask her to tell you in detail what happened when she and her husband last had intercourse. Explain that some women experience sexual changes during the menopause, such as vaginal dryness and difficulties in becoming aroused.
Mrs Jones tells you that her husband initiated sex after a night out; they had both had a few drinks and, at the time, she felt quite relaxed. Foreplay only lasted a few minutes; she has noticed that in the past few years, her husband has been having difficulty in sustaining his erection, so rather than lose it before penetration, they have both become used to curtailed foreplay and quick ejaculation.
She also says that she found vaginal penetration uncomfortable, because she felt very dry. She gained no pleasure from the event. She did not tell her husband about the pain because she believed this would have led to further discussion about intimacy, which she was trying to avoid.
Results and management
All her blood test results are normal, but the vaginal examination reveals vaginal atrophy, so Mrs Jones should be given some advice about localised vaginal treatments.
At the follow-up visit, she tells you that she feels her tiredness is now more manageable because her symptoms have been taken seriously. She is relieved that the tests were normal and now feels confident to address other concerns, especially the lack of intimacy in her marriage.
Further discussion reveals that she had been lonely when her children left home and anxious about coping with hot flushes and lack of sleep. She knew that she still loved her husband and wanted to be close to him. When she started to experience pain during sex, it had caused her great distress and a real sense of sadness.
She realised that she did not feel confident enough to talk about the problem and could not find the words to properly express her feelings to her husband. The tiredness was real, but it also had the function of maintaining distance from her husband and sabotaging intimacy.
- Victoria Lehmann is a sex therapist at Brighton & Hove PCT
- Take all of the patient's symptoms seriously; validate and respect her concerns.
- Organise appropriate blood tests (FBC, TFT) and explain all of the treatment options available to her.
- Draw a picture of the vagina and ask her to show you on the picture where she experienced the pain or discomfort.
- Ask the patient if she would like a chaperone to be present during the vaginal examination.
- Discuss any urinary problems.
- Give the patient information leaflets about the menopause. Ask her to show them to her husband. This will help them both to find a language in which they can discuss intimacy.
- Provide information about vaginal lubricants and HRT. Armed with accurate information, the patient can make an informed choice about the most appropriate treatments.
- Make an appointment for the patient and her husband to attend as a couple.
- Explain that some men also experience sexual problems as they age and it is important for her husband to attend for a medical check-up. This will help to engage them both and give them the confidence to talk about their problems.
- Organise an early follow-up appointment to maintain support and encouragement.