When menopause strikes, topics like sexuality and vaginal changes are oftentimes hushed convos in our community. Many women are also pitifully unprepared for what is coming down the pike with regard to the changes ‘down there.’

Obvious vaginal changes like graying, loss of pubic hair, dryness, thinning, opening and length shrinkage, and penetration irritation are pretty commonplace. The vagina also becomes more prone to not only urinary tract infections and bacterial vaginosis (discharge, itching, odor) but STDs.

50BOLD chatted with Barbara DePree, M.D., a gynecologist for over 30 years, menopause care expert, and author of Fearless Menopause: A Body-Positive Guide to Navigating Midlife Changes to discuss a few of the sexual and vaginal changes that come with the ‘Big M.’

50BOLD: Does the vagina change after menopause? If so, what are the changes that take place?

Dr. DePree: When your estrogen supply begins to diminish, your skin and other tissues lose collagen—the substance that keeps skin supple and youthful-looking. Loss of collagen causes vaginal and genital tissue to become thin and dry. You may also notice that your vagina no longer lubricates well when you become aroused. This is called vaginal atrophy, and it can make sex very uncomfortable. Vulvovaginal atrophy can also exacerbate urinary tract infections and cause burning, itchy genitals.

50BOLD: What happens to a woman’s libido after menopause?

Dr. DePree: As we enter menopause and our hormone levels drop, spontaneous thoughts about sex and responsiveness to opportunities for sex diminish for most of us. That’s natural and normal. You say you find your partner attractive, you have a good relationship, and your gynecologist gives you a clean bill of health. And yet, you’re having trouble getting aroused.

(We recommend the Vibe to aid with arousal, its shape, and flutter tip are designed for focused stimulation. The personal massager can be used solo or with a partner. You can use it as before play; the gentle suction and vibrations increase blood flow to your genitals, which increases responsiveness–and lubrication, as well; $49,

50BOLD: Can testosterone cream really boost sexual interest and activity? Is it safe, and has it been tested, especially with regard to breast cancer and heart disease?

Dr. DePree: Testosterone has been called the ‘hormone of desire’ for women. In many studies over the years, replacing testosterone has been linked to greater sexual desire, more intense orgasms, and improved sexual performance in women.

However, testosterone therapy remains controversial.  Unlike in men, there’s no direct relationship between libido and blood testosterone levels in women.  Additionally, appropriate levels of testosterone for women have been hard to establish since we produce so little of it.

Before beginning testosterone therapy, it’s important to address other causes of loss of libido such as depression, medications, painful intercourse, lack of emotional intimacy, or even chronic stress. For some women, testosterone is a game-changer, and for others, not so much. Since the potential benefit is so positive and the detriment is minimal, in my opinion, testosterone therapy can be a solid treatment option. Always consult with your healthcare provider to discuss available therapies.

50BOLD: What is your ‘vaginal maintenance plan?’

Dr. DePree: Generally, a maintenance plan for a healthy vagina and pelvic floor involves:

  • Moisturizers. Use vaginal moisturizers like Replens regularly—two or three times a week. Vaginal moisturizers help hydrate vaginal walls and maintain a normal pH balance. Your doctor might also prescribe a topical estrogen, which restores vaginal tissue to pre-menopausal conditions without being absorbed into your system.
  • Lubricants. Apply lavishly before and during sex to ease discomfort and add an element of fun.
  • Kegels. These exercises are done to strengthen your pelvic floor muscles that you use to stop the flow of urine mid-stream when you are sitting on the toilet. Strengthening these muscles helps you prevent urine leakage, prevent accidentally passing gas or poop, and even improve your orgasm.

50BOLD: Why do menopausal women have vaginal pain and dryness? Can women still orgasm after menopause?

Dr. DePree: The truth is that vaginal dryness does not end the intimacy you have with your partner or the afterglow you experience yourself after sex. Yes, it’s likely hormones. As estrogen levels decline, the vaginal lining changes. It becomes more delicate and less stretchy. There’s less lubrication and less circulation. Vaginal dryness is a typical first sign of vaginal atrophy when vaginal tissues shorten and tighten; it’s common, you aren’t alone, and you aren’t deficient.

If you are just noticing some discomfort, you can take the easy step of adding a long-lasting silicone lubricant to your foreplay, like Replens Silky Smooth or Wet Platinum. Next, you can add a vaginal moisturizer.  While lubricants provide temporary comfort and reduce friction during sex, vaginal moisturizers such as Replens, work to feed and strengthen vaginal tissues around the clock. I recommend an application of at least twice a week.

Menopause isn’t the end; it’s only a transition, which we as women have a lot of practice with. Take heart and take charge!

50BOLD: Will doing Kegels help with incontinence?

Dr. DePree: Bladder misbehavior in the form of incontinence and urinary tract infections (UTIs) is a common female complaint, and it tends to become more common and more troublesome as we age. This is because decreasing estrogen affects genital tissue and muscles in unhelpful ways.

Do Kegels!

This critical exercise for strengthening and toning your pelvic floor is your first line of defense against any weakening, sagging, or leakage. In several studies, Kegels were the one non-surgical treatment for incontinence that actually seemed to make a difference.

One way to challenge yourself and ensure you’re exercising the right muscles is with Kegel weights or balls. Firm up those pelvic floor muscles, and you’ll help all those downtown organs stay where they belong. Kegels may not completely end all your incontinence issues, but they’re the place to start.