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Hi guys. Good evening and welcome to tonight's dash webinar. Thank you for being here on this Tuesday night. It's not Tuesday, is it? It's Wednesday, Wednesday night. Apologies. Um My name is Alice. I'm one of the government trainees in Birmingham and also um the ST one of the slash education leads. Um and it's my pleasure to introduce tonight, Doctor Jessica Gy, who's gonna be speaking to us about sexual health in menopausal women. Um She's a consultant in HIV and Gum in bars in London and has a special interest in female sexual health and has done a number of research projects on this in the past. She's also got her menopause professional care certificate and is a member of the institute psychosexual um membership. So thank you so much for agreeing to speak with us today if you've got any questions. Um Please do pop them in the chat and we'll answer them as we go a long slash at the end of the speech, end of the talk. So doctor over to you. Thanks very much, Alice. It's really kind. Um I'm just trying to open my presentation which was working two minutes ago. I can still see it on the screen but has it closed on yours? I'm just trying to share it again. Let me how frustrating when this happens, isn't it? Ok. You should see something frozen. I've gone right the way into the middle, right. So, um I'm Jess G, thanks very much for the introduction and I'm a consultant in sexual reproductive health. And this is a talk which I gave um for the um um British HIV Association, sorry for bash um sexual wellbeing um conference and then again at Chelsea and Westminster. So I hope no one here is from Chelsea because you will have heard this exact talk a month or two ago. So I've got no um disclosures relevant to this presentation. I've not received speakers' fees for anything related to menopause or sexual health. And I did write this with people from lived experience, although I do not do not have lived experience of menopause. I admit that the language is going to be mostly focused here around c females, transfe um trans, male and non individuals obviously also experience menopause if they haven't attacked ovaries. And I did do a search into studies into experiences beyond cis women, but it was really sparse. And I got this quote that there really needs to be more equality and more research into people who are impacted just by menopause and not just cisgender, heterosexual women, which is obvious, isn't it? In? We find frequently across research So I'm going to talk about sex and menopause from a very sexual well being focus and it's going to have a biops psychosexual approach. I think it's really necessary to think generally about sex, but particularly, and menopause in the context of the cultural and social landscape which surrounds the individual patient, which we have sat in front of us. I'm going to refresh our knowledge around menopause very briefly because II expect a lot of, you know, might know more about it than I do. And I'm going to think about the holistic management of sexual issues around the menopause. So I want to always with these talks bring um focus on to sexual wellbeing as thinking about it as part of but not the same as sexual health. So we know that good sexual health is a marker for general wellbeing. It's important to move away from this old language of dysfunction and function, which is thinking about what we can or can't do and towards a more pleasure centric focus. And I included changing times in the title of this talk to, to reflect not obviously the changing times and things that happened during the menopause, but also the change in our expectations around sex and the change in lifestyles, which covers also the change in our work patterns and technology. I've previously done talks on um feminist perspective on sexual wellbeing and sex and have considered societal and gender norms, social justice and sexuality and I think we need to carry with this in our heads. When we're thinking about this topic, we need to think about also how, you know, gender disability class or race might play into experiences of our, of our patients around us. So, in menopause, it's the cessation of menstrual periods following loss of ovarian function. This happens at an average age of 50 to 52 with some variation between different countries. It's usually a gradual process unless it, there's a surgical menopause when your ovaries are removed. Um So it's grad gradually periods becoming more regular, but people can have periods that stop suddenly um through natural menopause. Perimenopause is the period around a menopause when women are getting irregular periods and menopausal symptoms, the average um timeframe for menopausal symptoms is is seven years, but people can have perimenopausal symptoms for up to 20 years. We use the term post menopause when someone's had no period for one year. And cis women will spend 40% of their life in menopause if we're lucky. So it's really worth thinking about thinking about this. So, menstrual cycle, I think I'm sure I'm teaching you to suck eggs. But um follicle stimulating hormone is released centrally and the brain stimulates the growth of ovarian follicles and thereby um obviously estrogen. This um increase in estrogen causes a surge in LH and that leads to um ovulation within a day or two of that LH surge then left behind from this ruptured follicle is the corpus luteum. And that corpus luteum obviously produces estrogen and progesterone. The estrogen levels decline as that corpus luteum degenerates. And then we get a triggered FS H rise. And I think this is important to bear in mind because thinking about how we diagnose menopause if we're using blood tests, obviously, that that's why we need more than one blood test and that's why they're not a great way of diagnosing menopause. So transitioning through perimenopause and menopause, the symptoms of perimenopause and menopause. They're, they're associated with falling and fluctuating estrogen if you think of it about if you think of this as sort of FSH resistance. So your um body is producing more and more FSH in an attempt to flog the ovaries to get them to produce estrogen. So, as I said, we need to diagnose menopause really clinically through the constellation of symptoms and um and, and, and, and what we're putting together clinically and routine testing of SSH, really not advised to diagnose menopause outside of diagnosing premature or early menopause under the age of 45. So, estrogen episodes fluctuate widely during perimenopause it. I couldn't find an idea graph. So these two are just ones that I've got, but it gives you the, it gives you the general gist, doesn't it? So, estrogen is going up and down. So that's why you're getting hot flashes and mood swings and sleep disturbance. Um I've just bung this slide in cos I think it's really important just as a reminder that we need to approach menopause holistically and not just consider the hormonal and physical changes, but consider the social and cultural issues around this time of life. So this these, these changes in turn impact how a person feels about themselves and how they're viewed in society. So we have a Western association with aging and loss of sexual vitality, but it's worth remembering that this is possibly not how menopause is seen across the world. So we might come across patients that have different attitudes and, and perception and perceptions than we do. And it's important to not make assumptions and to ask people how they feel about, about these changes. So does menopause affect sex? I think there's slightly conflicting data when I, when I, when I sort of asked this question. Um but perhaps it is dependent on how the question is asked in research. So the time around the menopause is certainly testing for sex lives, but it's not just testing because of hormonal changes. It's testing because of other stuff which is going on people's lives basically. Um Yeah, so we need to think about again, beyond hormones. So the, so the British menopause Society commissioned this independent organization, Ipsos Mori to do a survey where they looked at 1000 women through the ages of 45 to 65 and 50% of those had said that menopause had experienced. Um had affected their, had affected their sex life. And then that cell um that cell from over 10 years ago, that Cell three took in depth interviews from women um 23 of them and really looked at how their perceptions of menopause. But few links their menopause with a decline in the quality of for of sexual activity. And they were, I'll go into this in more detail, but they were much more likely to attribute it to other causes and other factors. So when I was sitting in menopause clinic um as part of my M CPC, which I can talk to you about if you're interested. Um these were the constellation of symptoms that would persistently come up. So, fatigue, anxiety, vasomotor symptoms, joint pains, depression, juice, libido, cognitive changes, worsening of existing mental or physical health conditions. So people would often say my adhd has got worse or my fibromyalgia has flared up again. So changes to skin hair and body compositions. So physical, the um uh physical elements obviously came up a lot and, and when I sort of think what can hear can affect sex and how people's and people's perception of sex, really, all of them are gonna affect how you, how you feel about your body and how you feel therefore about sex. Um A relevance to that idea is the dual control model. And I don't know if anyone's come across this before, but this is um the idea that there's two separate excitation and inhibition circuits which exist in the brain. And you need to have, um if you think of these as an accelerator and a break, then you need to have these two circuits which are cooperating in order to achieve sexual excitation and sexual response.