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How PCOS Can Affect Your Sex Life

Having PCOS is like being dealt a hand of genetic cards. You can play those cards so that you feel your best, sexually and in terms of your energy and mood. Your lifestyle, your diet, and hormonal management are all important pieces to manage the hand you have been dealt.

First thing to know is that you are not alone: one in ten women has a similar set of playing cards. PCOS (Polycystic Ovarian Syndrome) is a common genetic hormonal pattern in which your DHEA (an adrenal hormone) and your testosterone are robustly influential in relation to your ‘female’ hormones (estrogen and progesterone). Even though testosterone is widely accepted as the hormone of desire, if you have too much, you will not necessarily have a high libido. You may still have similar desire problems, or arousal and orgasm problems, as women without PCOS, though not for the same reasons. 

Twenty percent of the women I see in my practice have this hormonal pattern and I have found multiple things that work to balance you emotionally and physically, as well as improve your sexual experience. Let’s start with the basics, your period, and then go on to hear how PCOS interacts with your sex life, and what you can do about it.

With this hormone pattern women often experience problems with their periods—skipped periods, frequent periods, heavy bleeding, extra long periods, severe cramps, or no periods at all. Sometimes providers prescribe oral contraceptives to manage the pain and the bleeding, and to make the cycles regular. Women who have heavy and/or long periods can bleed so much that they become anemic. If you have anemia you can become so tired from an iron deficiency that you don’t have the oomph to be interested in sex. On top of that, it can seem to your partner that you are always on your period, and never available for sex. Misunderstanding around this can lead to distance and resentment in your relationship.

Even if periods are regular, with the extra androgen influence, women with PCOS are more likely to have cycles without releasing an egg. Without that mid-cycle hormone spike, you are less likely to experience the surges of desire, the ‘horniness’, mid cycle. Also, when you don’t ovulate you don’t produce much progesterone. Progesterone is the relaxing hormone in your chemical mix. You have estrogen and testosterone in that mix and those are both activating; progesterone balances that activation with relaxation. You have receptor sites in your brain for progesterone and when it lands there, you can feel mild sedation and calmness. When your progesterone level is low your sleep can be restless, you toss and turn, you can get sweaty, and you don’t wake up feeling restored.

Women with this hormonal pattern of PCOS report to me having night sweats, itchy or hypersensitive skin, and greater anxiety and irritability—sometimes too irritable to want to be touched. They also are, according to research, more likely to be depressed.

Also, If you have PCOS you are more likely to struggle with weight, and be at a higher risk of diabetes. The increase in testosterone increases the size of your muscles. Sometimes this works for you, and sometimes your muscles bulk up more than you want. This bulking up increases your weight and excess body weight can contribute to a lack of desire for sex. Many women who gain weight become self-conscious about their weight. It inhibits them from wanting to be seen naked, and so they refrain from initiating sexual contact.

Not all women with PCOS have or are going to have all of these symptoms. Many women with PCOS have no sexual problems, none at all. There is a large variation in how women with PCOS are affected. One third of women with PCOS will struggle with decreased fertility, and having sex will be linked with using ovulatory kits, and jumping in bed when the timing is ‘right’. Some women will have extensive medical workups for this and be on medications that influence their mood and desire. PCOS is not one thing — the underlying hormonal pattern of PCOS is there, but the expression is different. With genetic studies, we are still learning why this expression is so varied and how we can intervene.

Besides low sexual arousal and desire, women with excess androgen hormones can complain of vaginal symptoms including burning, dryness, or irritation. Some women report their own lubrication does not last long enough for them to finish sex without needing to add a lubricant. Sometimes there is ongoing itching and burning of the vagina that gets worse at certain times of the month.

Ann had this PCOS hormonal pattern. It was her anxiety and irritability that brought her in for a hormone evaluation. Specifically, it was the flush of embarrassment on her twelve-year-old daughter’s face when she, Ann, angrily demanded that the man in the ice cream truck turn down his annoying music. She recognized that her reaction was over the top and she was tired of being on the edge. On her intake form, Ann marked her symptoms— anxiety, irritability, vaginal dryness, specifically vaginal burning after intercourse, low libido, restless sleep, and worsening PMS. She had felt on edge for a few years and the number of days she felt moody was on the increase. Her sexual desire had been low for years. Vaginal dryness had started after the birth of her second child and was getting worse. Lubricants helped intercourse feel comfortable, but she was not that excited about having intercourse at all. She had sex because she knew it was important to her marriage, and she did like the closeness she and her husband shared after sex.

The vaginal dryness and burning that is sometimes found in women with PCOS is easily treated. Ann found this to be true. Eight weeks after she began treatment, her vagina felt back to the way it was before she had her second child. She no longer had dryness, and she no longer burned for a few days after being sexual. These vaginal symptoms responded quickly to the same estrogen treatment used for menopausal vaginal dryness : a topical low dose estradiol cream, or suppository used once a week.

Ann received a prescription of micronized progesterone, and with it she felt more relaxed and was able to sleep longer and deeper. She no longer experienced on the edge, moody feelings. She still felt anxious at times, but the feeling was slight in comparison. Her husband could approach her without her snapping at him. His touch, which had become annoying, felt good again. Intercourse was distress free, and she felt stronger levels of arousal than she had in years.

Ann did not have the anemia, but if she did she would have been given an over the counter iron pill to take daily and advised to increase the iron rich foods in her diet. About one third of women with PCOS have heavy periods. Heavy bleeding is defined, in medicine, as a need to change your pad or tampon every one to two hours. Long periods are defined as ones that last longer than seven days. Treat the low iron until your hemoglobin and hematocrit are in the normal ranges. Sometimes prescription iron is recommended. Also, if your provider doesn’t test your ferritin level (a measurement of stored iron), ask for it. Clinically, I notice women with ferritin levels greater than 50 report a stronger sense of wellbeing and are more likely to have some energy left for sex when they get into bed at night, than women with ferritin levels below 50.

Also, your health care provider can help you look at several treatment options to help you modify the heavy bleeding. Some of your options are friendlier to your arousal and libido than others. When your hormones are managed well, you will have more regular cycles, and probably lighter periods. You will discover you have more choices around which days to be sexual, and more energy with which to have it.

Remember, there is nothing ‘wrong’ with you and you are not alone. One in ten women are managing this too, and more genetic studies are underway to increase understanding and optimize health.

Symptoms of Too Much Testosterone in Females

  • Acne
  • Restless sleep/Insomnia
  • Irritability
  • Anxiety
  • Short fuse/Anger/Rage
  • Worse PMS
  • Menstrual Cramps
  • Weight gain/Bulking up
  • Irregular periods/No periods/Heavy periods 
  • Increase in chin and lip hair and hair elsewhere on body and a thinning of hair on top of the head
  • Vaginal irritation and/or dryness

This is an edited excerpt from Fanning the Female Flame-How to Increase Sexual Desire (without Changing Parters).

Question: Do I need to get my testosterone level tested?

Signed, a woman with little to no desire for sex

Of the low libido women who come to see me, roughly two or three out of twenty will have testosterone levels low enough that I identify it as a contributing factor to their low sex drive. Could that be you? It is important for you to know the answer. The list below gives you a reasonable idea if you are a woman who should get tested. Check the symptom list — If your testosterone levels are low you most likely will have at least three or four of these symptoms. It won’t just be that you have no desire for sex. Testosterone affects your whole body, so low levels affect your muscles and your mood too.

Here is the list of things that can happen when your testosterone is low:

  • You feel tired
  • You have less endurance
  • Your muscles aren’t strong, and even when you work out you don’t get much result
  • Your mood is low, and you feel a physical kind of depression
  • You are less optimistic than you used to be
  • Overall sexual touch doesn’t do as much for you as it used to–there is a dullness to the sensations in your vagina and clitoris
  • When your nipples are touched you no longer get aroused
  • Your vulva can feel as if it is burning
  • Your vagina has tears in the skin after intercourse, or can occur spontaneously
  • You will have less lubrication in your vagina when you are aroused
  • The amount of hair on your body is less, and the quality of your hair is thinner
  • You aren’t thinking about or planning for sex
  • Your memory is not as sharp as it used to be

GETTING TESTED: If you have three or four of these symptoms then ask your provider to test your levels.

Tests should include a Total Testosterone, and a Free Testosterone. SHBG (Sex Hormone Binding Globulin) will also be calculated to figure out how much of your testosterone is available for you to use, as it can be bound by this protein. If your tests show that you are deficient (below normal range) or low normal (low normal is the bottom 25% of the normal range) you may be a candidate for treatment.

More about testosterone in my book: Fanning the Female Flame

Click here to read about how PCOS can affect your sex life.

In the coming weeks, I’ll be writing about how to treat low testosterone.

Sex Doesn’t Have to be Painful

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“Treat Your Vaginal Dryness Early” are the words I would put on large billboards along I-5 and along other major highways in the US. I want to get the word out to women sooner about this common problem. Many women I see have waited months or years to seek treatment, and I cringe at the number of nights they have been in pain. Or the number of nights they are ambivalent about having sex as they face the no win choice of either “sex with pain” or “no sex”.

 

 

Treating women’s dryness early would reduce that personal pain and burning during and after sex, and it would do so much to maintain the closeness in marriages — the closeness that can wobble when this happens. So don’t wait. There is no reason to wait. Vaginal dryness, particularly menopausal vaginal dryness, is progressive. The earlier you treat it the better.

Treating dryness early would not only reduce sexual pain for women, it would also improve the capacity for arousal and the quality of the orgasms of millions of American women. On top of that it would add quality to the sexual experience of the women’s partners. As far as what it would do for relationships, well that is a lot. When a partner isn’t available for sex there is confusion, distress and sometimes a misinterpretation of the source of the problem. Treating dryness early would make this relationship chaos less.

Vaginal dryness occurs in more than 50% of women experiencing menopause. It also occurs in young women. Usually these young women are on hormonal contraceptives like the birth control pill, hormonal IUDs, and implants, or they have a hormone condition called PCOS (Polycystic Ovarian Syndrome). Significant sexual pain occurs in 10% of young women who go on the pill because of vaginal changes that occur from taking the pill. This intimate pain is quite a negative introduction to the new world of sexuality for these young women.

Whether vaginal dryness is due to the pill or menopause or other conditions, it is quickly and easily treated. Don’t wait. The symptoms of pain with intercourse or the feeling like you have a rug burn after sex, will resolve in six to eight weeks. And the treatment is safe. It doesn’t increase your risk of getting breast or endometrial cancer (links to the research on safety are included later in article).

There are multiple treatments for dryness, and there are a few new ones. Intra-vaginal DHEA is one that I reviewed in the last newsletter. More new treatments, including laser therapy, are gathering data now. Low dose minimally absorbed estradiol is still the go-to treatment for dryness. Below is the handout I give to women when prescribing this medication.


USING LOW DOSE MINIMALLY ABSORBED VAGINAL ESTRADIOL

You have been prescribed a vaginal estrogen preparation to use topically.

This prescription is to treat vaginal dryness related to loss of estrogen, or for some women it is to replace estrogen when “crowded out” by naturally higher levels of testosterone.

This is a prescription that you pick up at the pharmacy.

This medication is a low dose hormone prescription. It is different than a lubricant, and different than a vaginal moisturizer. You can think of it like a conditioner.

You do not use it before sexual activity.

The hormonal changes that occur to the vagina also affect the tissue around the opening of the vagina and the urethra (the tube that creates the passage where urine leaves your body). When a topical estrogen cream is prescribed, often the instructions are to take ½ the dose and apply around the opening of the vagina and the labia (lips) including the clitoris and clitoral hood. The other half of the medication goes into the vagina using the applicator from the pharmacy. You also can use your fingers to insert the cream internally.

If you are beginning the prescription, you will often be advised to use it daily for a week, then reducing to twice a week. It takes six to eight weeks for the tissue to get back to the thickness it had been before the hormonal change. When your symptoms are gone, you can reduce the prescription to once a week. If symptoms reoccur you can then increase again to twice a week. If you have been using it for 8 weeks and you still have dryness or pain, come back in — something else may be going on besides vaginal dryness.

Prescriptions for inside the vagina are also written for rings (Estring: this is a ring that is placed inside the vagina and releases low dose estrogen for three months) or suppositories (Vagifem or custom compounded suppositories). These methods deliver estrogen to the vagina internally. Often when a woman uses rings or suppositories internally she will still benefit from some estrogen cream applied externally around the opening of the vagina where more pressure occurs particularly with thrusting.

Compounded vaginal estrogens can be made in creams without parabens and propylene glycol and other chemicals that irritate when cracks or fissures are present, or when there is skin sensitivity. There are bio-identical options for both compounded and non-compounded prescriptions.

Vaginal Estrogens have not been shown to cause an increased risk of breast or endometrial cancer, or any other cancer. See the 2016 American College Of Gynecology guidelines here for women who have had Breast Cancer, and their use of estrogen, click here to visit.

The use of low dose vaginal estrogen and risk of stroke continues to be under study, and so far the Estring, and low dose topical creams show no increase in blood clots, click here to visit.


THE BOTTOM LINE: Don’t put up with dryness or sexual pain from dryness. Find out the cause and treat it until it is gone. There are many resources to help you be successful with this safe treatment, so if your provider doesn’t ask you, then you ask them for treatment.

Click here to read my article about why there is no better time in history to be a post-menopausal woman who wants to have a great sex life.