Podcast Episode 2: Changing the narrative about sex during the perimenopause and menopause with Claire Macaulay

Claire Macaulay’s interest in helping individuals with their sex lives arose from working as a breast cancer oncologist and seeing women coping with the effects of a medically induced (or worsened) menopause as a result of their breast cancer treatments. She then trained as a sexological body worker and somatic sex therapist to support women to have sexual expression that’s meaningful for them, as well as using hormonal treatments to improve the physical symptoms of pain or dryness that occur.

Within healthcare, professionals often assume the vast majority of their menopausal patients are having problems with their sex lives (and it may be around 70%), yet it’s not something women will usually speak about. Claire explains that her sessions reveal many people think they’re broken, that there’s something fundamentally wrong with them or that they’re going mad. Claire discusses the need for exploring ‘what does it mean to live a sexual life?’ ‘What would you want?’ And how creating sex positive spaces to discuss these issues can help combat the shame and guilt that often presides.

You can find out more about Claire and her work at www.pleasurepossibility.com.

Podcast Transcript

Lauren Redfern [00:00:06] Welcome to the podcast for the Newson Health Menopause Society, a multidisciplinary collective of interested professionals passionate about improving hormone health across the world. The society exists to educate and inspire others to raise the standard of menopause care and access to treatment, to facilitate research collaborations across specialities and countries, and to provide expert advice and guidance to our associates. The ultimate aim of the Newson Health Menopause Society is to improve the lives and future health of women and all who experience the perimenopause and menopause. I’m Lauren Redfern. I’m a medical anthropologist, and I’ve been exploring the experiences of those using testosterone as part of their HRT treatment. In this podcast series, I’m going to be talking to guests from a variety of different disciplines in order to share knowledge and ultimately improve our understanding of the perimenopause and menopause.

Lauren Redfern [00:01:05] Anna was 43 when she started to experience extreme pain in her vagina, pelvis and inner thighs. Following a hysterectomy, Anna’s symptoms became more severe and she was forced to give up work. Anna explored numerous options in search of relief for her symptoms, but it took her more than a decade to discover that HRT and localised vaginal estrogen could help to improve or even resolve her symptoms. I wanted to share with you some of Anna’s story today in the hope that it can allow us to begin thinking about the ways in which sex and the menopause are inextricably and importantly linked.

Lauren Redfern [00:01:39] Speaking about intimacy with her now husband, Anna explains that whilst they had a good sex life, it took her a couple of days to recover after they’d been intimate. This is Anna in her own words, ‘the pain after sex was awful and would sometimes keep me awake all night. My GP referred me to the pain clinic and I was prescribed duloxetine and amitriptyline for nerve pain. When these didn’t work, I was given gabapentin and finally fentanyl patches, which made my skin erupt. None of them worked. As a last resort, I was put on morphine tablets, then methadone. I could no longer work full time and I felt like a zombie. I was in excruciating pain, especially when my period was due. I felt like something was pushing down between my legs – and sitting was a nightmare. I went to a neurologist who did an MRI. She said everything looked fine and then they referred me to a gynaecologist. At this stage, I could hardly walk.’

This is just a short extract from Anna’s account. Her full story details extreme struggles with debilitating symptoms, an exhausting process of consistent referrals, and a frustrating battle to have her voice heard by the clinical professionals she was coming into contact with. In amongst it all, however, is the very real, very important voice of a woman in incredible distress struggling to maintain life as she knows it, including the ability to engage in and enjoy an intimate relationship with her partner. Joining me today to talk about the important and fascinating relationship between sex and the menopause is Dr Claire Macaulay, who is an oncologist and self-identifying sex science geek. Hi, Claire.

Claire Macaulay [00:03:08] Hi Lauren.

Lauren Redfern [00:03:09] Thanks so much for joining me today. I’m really excited to chat to you about all of the things to do with sex and menopause, and would you be kind enough to introduce yourself and tell us a bit about the work that you do?

Claire Macaulay [00:03:19] Thank you, Lauren. I’m delighted to be here. Yes, so I am a breast cancer oncologist, which is really where my initial interest in menopause came from because we render a significant portion of our patients menopausal with the treatments that we give them, specifically if they’ve got hormone receptor positive breast cancer. And what became apparent to me was that we weren’t necessarily always completely open with people about what they might experience as a result of that, particularly in relation to their sexual functioning, their genitals, how they may feel. And when I started to ask people then – and that was the amazing thing, the minute you make space for people to say, ‘You know, how are things? Are you experiencing?’ And then people will tell you. And I had one woman who has metastatic breast cancer, so she will ultimately die of breast cancer – not anytime soon because she’s on treatment – who came in, sat down, cried and said, ‘Not being able to have sex with my partner is worse than knowing that I’m going to die of breast cancer. I’m going to die anyway and I can’t have sex.’ And at that point I began to realise it’s a real issue here, and then trying to extrapolate that out wider to the menopausal experience more widely and that took me to then training as a sexological body worker, which is a somatic sex therapist where we actually use the body and to looking at the experience of people who are experiencing the menopause and what it means for them and their sexual expression.

Lauren Redfern [00:04:41] In relation to sexological body work. Could you tell us a bit about how that works and what the process is?

Claire Macaulay [00:04:47] Yes, sexological body work is a modality where we use people’s bodies to help them learn whatever it is they want to learn about sexuality, and that might also include touching people’s genitals. So yes, I might touch people’s genitals. The important part about sexological body work is that the touch is only one way. So clients are not touching me. We’re not having a sexual experience. I am touching the clients in service of what it is they want to know or they may be touching themselves. And I am always wearing gloves if we’re doing any intimate touch. So we’re not having the experience that we’re having in the body is devoid of any relationship we might be having between us. And certainly, the practice of sexological body work is one way touch wearing gloves.

Lauren Redfern [00:05:23] And I suppose, as you’ve said, creating a space in which a person feels empowered around being able to set boundaries for how they would like their body touched and how they would like to touch their own body and practising and advocating for that.

Claire Macaulay [00:05:35] Yeah, absolutely. So the client is entirely in control of the touch that happens, where the touch happens, and they are leading the way in terms of what it is that we’re experiencing at that time. And that’s actually most of the important part of it is about boundaries: expressing what is that they want to experience, that they are in control. Because for many people perhaps have experienced trauma, they may have had all of that taken away from them. And so we’re trying to repattern their experience that they can be with another and be in control. And what does that feel like in their body.

Lauren Redfern [00:06:06] Amazing. And I want to expand a bit on that because I was reading a bit of information about your approach and you have discussed, I think, on your website, drawing on modalities as widespread as new tantra, orgasmic yoga, somatic sexology and erotic intelligence. And this, for me, was just, I mean, amazing anyway, because I just was like, ‘Wow, I want to know more about this’, but I wondered if you could tell us a bit more about them and how they feature in your work and how that crosses over? I guess you’ve touched on that a bit, but I’m really fascinated to know a bit more about the interplay and how you bring those into your practise.

Claire Macaulay [00:06:41] Yeah, I think that one of the things that’s really at the core of how I choose to work is understanding that our bodies have their own innate intelligence and they also have their own innate aliveness, almost. And if we simply tried to think about sex and sexuality and sexology as a top-down modality, so something that we think our brains and think are down into our bodies, we’re kind of stuck because the anatomy, the functioning starts within our bodies who actually are there and involving the mind because it’s all important. But a lot of the sort of societal conditioning means we don’t talk about our body. You know, we have the concept in sexology that we talk about, which is this idea about the genital whole, meaning that our body ends bottom of our bellies and start again at the top of our thighs, and we’ve not really felt a sense of what happens in between there. And so if we want to support people to have sexual expression that is meaningful for them, it needs to come back to bringing them to their whole. And that’s the approach that I take. So that’s… The somatic part of it means of the body, so can we help people to learn and understand the feelings and sensations and experience of their body in addition to the feelings and experiences that they have in their mind?

Lauren Redfern [00:07:55] I think partly why I wanted to start with Anna’s account and her story – I mean, obviously it is quite shocking. Although, I had a really interesting conversation with my mum about it and she was saying, ‘You know, the majority of people I know who have been through menopause, it’s not uncommon to have a lot of issues with having sex.’ And when I was talking to her about that account, I was saying it was very shocking. You know, she said to me, ‘I don’t find that shocking, it actually sounds quite normal for what I’ve heard.’ And I think what I wanted to really ask and by starting with Anna’s story is this emphasis on the experience of perimenopausal and menopausal symptoms as physically debilitating and it having a real impact on women’s ability to maintain an intimate connection with a partner. And I mean, I think I wanted to talk to you a bit more about your experience of working with women who are experiencing these physical symptoms, these symptoms of pain and how we can look to appropriately help and support. Because I imagine in what you’re saying in reconnecting to the body actually and experiencing those painful symptoms, those debilitating symptoms, it can almost do the opposite. It can make you feel like you want to move away from connecting with your body. Dissociate out of your body.

Dr Claire Macaulay [00:09:06] Yeah, absolutely. And I think, you know, the thing about Anna’s story is, although that’s perhaps at the extreme end, it’s extremely common. Your mum is right. We know from all of the research around this, about 70 to 75% of people experiencing the menopause will have some issues with their sexual expression. So it’s not uncommon. And I think that that’s a really big deal. You know, if we’re thinking about healthcare professionals and people coming into contact with people experiencing the menopause, you can assume that the vast majority of people that you come across are having problems with their sex lives and they’re not telling you and they’re not telling anyone. And that’s where the issue comes. And that’s I think where the body can really help us, is that once we start to get to people owning that experience within their body, recognising what their experience in their body is, it is actually then easier for them to verbalise it in some way. Because what I find is people think that they are broken. People think that there’s something fundamentally wrong with them and only them. Also that they think they’re going mad because of the experience that they’re having. So let’s say it’s loss of sensation or loss of tissue. People will come and say to me things like, you know, ‘My clitoris is disappearing, I must be going mad.’ So once you start to be able to connect people with the experience in their body, it does then allow it to become real. Because actually, what I see a lot of the distress is that people know that it’s happening but think it shouldn’t be happening. And there’s a dissonance there between what their experience is and because no one else is talking about it. They either think they’re funny, or they must be making it up. So there’s something about coming back to the body there and also recognising that the vast majority of people are not particularly connected to their body in any event. Before we even get to the perimenopause or menopausal phase of life. And that can also have its own issues and the intimacy with a partner piece, quite often people will come to me and when we really dig into it, they weren’t particularly having an enjoyable, nourishing sex life before all of this. But the menopause becomes the focus for why they’re now not. But actually, when you start to unpick it, I find it really helpful to take people back to their body because you can go right back. Not just about their experience right now but actually how do they feel about their body? What do they notice about their body? If we take them backwards in time, how did they feel about their body when they were a child, in their 20s? Those kind of things, and the body has its own innate memory and wisdom. So when we’re working with the body, it can bring up a lot of things for people, which is why we need to be very careful when doing this that we’re trauma aware, trauma informed, etc. because a lot of things are held within the body that we can unleash if you like, when we start to allow people to feel things and you mentioned dissociation so that’s a classic way of dealing with things. I’ve got clients come who are phenomenal disassociaters and what you teach them is how to come back to their body safely, and usually that’s because people don’t feel safe in their body for some reason. How do we get them to come back to their body so that they can stay with their experience? Because once they can stay with their experience, it then gives them choices about how they want to go forward.

Lauren Redfern [00:12:13] Can I ask a bit on that as well? It’s just coming to me in this moment. It feels like there are a lot of contradicting narratives when it comes to –particularly for healthcare professionals – working with people around sex and the body. So one minute you hear ‘touch can be incredibly triggering’. ‘Do not offer touch, always ask for consent.’ Which is obviously incredibly important. But it is interesting to hear you talk about very touch-based work, which makes sense, right? When you’re working with coming to terms with your body or relearning your body or learning intimacy around your body, it makes sense that you would be drawing upon touch-based practices. But how have you found that and navigating that within a healthcare field where there are so many, you know, competing narratives for what the best approaches are to take?

Dr Claire Macaulay [00:13:02] Yeah, I think that’s right. So there’s no doubt about it that it is edgy work to say that I am dealing with people’s genitals. I mean, that of itself in the society that we’re in, in the culture. And that’s very edgy to say that. What the important part of that is of course, you don’t just go in and touch someone’s genitals. I may never touch anyone’s genitals. We only use things like touch-based therapy if it’s in service of what it is that they want to learn. And the foundational piece of all of that is before we go anywhere near any of that, we do lots of work around consent boundaries. How do you express yourself? So actually the other fundamental things that are important to people in their lives. Because often people’s boundaries have been crossed, they’ve been touched without consent. So what you’re doing is you’re giving them a felt sense of what is it like to have someone respect your boundaries? What is it like to ask for what you want and get only what you ask for, what is it like? So we’re kind of repatterning people’s nervous systems in terms of what that experience is, whilst being very aware that we may trigger things in that process, but we’re desperately trying not to do that, but we have to be aware that that’s probably there and all by putting them at the center of what happens. So when people come to me for example, they don’t come for therapy, they’re not fixed, they’re not broken. I don’t fix them. They come for an educational and coaching experience. So they are in control of the narrative. They’re in control of what happens. They’re in control of any touch that takes place. They ask explicitly all of those kind of things to try to make this a safe way in which people will have experiences that counter their previous experience to help them move forward in some way.

Lauren Redfern [00:14:33] Absolutely. And I mean, I think that’s interesting in relation to the narrative from Anna that we presented is that I think there is something quite debilitating and hard around having that consistent process of referral where your body is prodded and poked and touched in a manner where you lack agency, where you’re unable to talk about your experience as it pertains to you. So I mean, that’s interesting that in that space, whilst it’s touch based, it’s also very much patient led.

Dr Claire Macaulay [00:15:00] Yeah, absolutely. And totally led by the client. You know, at the end of the day that is the only way in which it works. And I know a number of people have come to me because they’ve got specific healthcare related trauma to whatever it is that’s happened to them, for example. And that is very much about being without agency. And that’s just one sort of form of trauma without agency, amongst many others that people might experience. So I think it’s important to understand that the focus of this kind of work is not to touch people for them to have an experience, although that is valid of itself. It’s about often the work of Betty Martin and the bill of consent. The choosing is more important than the doing. So is the fact that you’re able to notice, articulate, be in charge or be clear about, receive what you’ve asked for, have someone respect your boundaries. All of those things are more important, actually, than the touch that takes place.

Lauren Redfern [00:15:48] So I wanted to also ask you, I suppose it’s related in my own research. And yes, that is a shameless plug. I was really interested in thinking about how we start to define sex and intimacy, and a number of the women I observed and spoke with reported struggling to enjoy penetrative intercourse, particularly as a consequence of these symptoms such as soreness, dryness, pain, itching. But also, I think there was deeply held an association around the idea that penetration was what we meant by the term sex. And indeed, the primary way to both enjoy and engage in sex. And I wanted to really get your thoughts on this and about this and whether in your work, you encourage a broadening in approach to sexual intercourse between couples to include non-penetrative stimulation and whether exploring sex more holistically is a way that a person may be able to potentially increase pleasure and also reduce anxiety around touch or pain?

Dr Claire Macaulay [00:16:51] Yeah, you’ve absolutely hit the nail on the head there. So the first thing that people do when they come to see me, they fill in a very detailed intake form and that includes, ‘What messages did you get? Who told you what about sex? What education did you have? What messages did you internalise? What were your early sexual experiences? What does sex mean to you?’ You know, and almost universally, sex means a penis and a vagina. Where did we get this idea from? Well, we know where we got the idea from because it’s society and everything that you see, everything you’re societally conditioned to think about, is that’s what real sex is. And of course, if you’re working from that place, if that is your internalised belief that sex equals penis and a vagina, when your vagina, vulva is having difficulties based on that, then you feel that your sex life is over. And of course, that’s just one very small aspect. So often I will say to the people I say, you know, ‘You do know about the orgasm gap, and you do know that lesbians have more orgasms than when it’s a man and a woman.’ Let’s just take the idea that you need a penis in the room out of the equation, and then a bigger piece, they’re also about do you need someone else there at all? So there’s another piece there around what is it to be a sexual being? Is it to experience pleasure in your own body? And that’s my view. That’s where I start is I say ‘right, we’re going to take the word sex out of this altogether, and we’re going to swap it for the word pleasure’. And then if you can work with that narrative, ‘how does that change things for you?’ And ‘what does that mean in terms of what you might like to explore?’ So I say to them, ‘Let’s become a pleasure explorer. Let’s figure out what bits of your body feel good because there’s plenty more of you than just the bits that’s in your pants.’ That is important, and I’m not defining that, but actually, what else is there and what does it mean to live a sexual life? What does that actually really mean? And often when you say that to people, they’ve not got a clue, and the next bit after that is ‘ok, well what would you want?’ They also don’t have a clue about that either, so they don’t even really know what it is that they want. They feel often that they should be doing something that’s based on a narrative that they’ve learnt a long, long time ago and actually, what happens if we take some of that and flip it on his head and say, ‘Let’s start with pleasure’, what would that be?

Lauren Redfern [00:18:57] I mean, even this term ‘pleasure explorers’, I just feel that anyone listening please take up the baton of being a pleasure explorer and let us know. Let me and Claire know your pleasure exploring adventures, because I think it’s great also to think about the body holistically. I think is what you’ve talked about, too, that there are pleasure receptors in the same way. You know, it’s quite common that we talk about hormones in menopausal research and there being estrogen receptors all over the body, there are pleasure receptors all over the body. So different parts of your body may be more prone to pleasure than others, and that might be different for each individual.

Dr Claire Macaulay [00:19:28] So I think the other thing is that your sexual expression does not need to look like anyone else’s. For me, I use this phrase, ‘We are made from sex and stardust’. That is actually how we got here. We are made, you know, atoms from space. And we were created through the process of sex. So what would that mean then? What would it mean if actually you were meant to be a sexual being? You were meant to experience pleasure? Not at the expense of everything else in life. But that it was of an equal importance in our lives as human beings that we would experience pleasure, that that’s what we were given this for. It does seem like a terrible waste to have this amazing, phenomenal opportunity and not use it to its full advantage.

Lauren Redfern [00:20:11] And I mean, I think it’s also a broadening of the ways that we think about intimacy too, because in my own experience of observing and listening to women, something I noticed was so many stories in which guilt featured around pleasure and sex which was, ‘I don’t enjoy having sex with my partner anymore. However, I really feel like I should, therefore I do’. And that could result in quite painful bleeding, soreness after sex, and that has a massive impact on someone’s emotional and mental wellbeing. But it’s also complex as when we’re in relationships and we’re in partnerships, we are encouraged to think about sex as a part of that relationship. And I think inextricably that becomes linked to feeling responsible for your partner’s pleasure as well as yours. And I think it’s a huge burden for women to carry.

Dr Claire Macaulay [00:21:02] Yeah, which is just one of the many burdens that particular people, in particular bodies might carry, I think. Absolutely. And you use the word intimacy there. And this, I mean, you can very easily have great sex without intimacy. Very. You can very easily have pretty rubbish sex without intimacy. So the idea that sex and intimacy are interrelated to each other isn’t always necessarily true either. I mean, some of the most intimate experiences I’ve had have involved being with another person and not even touching them, eye gazing, for example. So this might be what intimacy is into me, I see, which is allowing someone else to actually see who we are and actually be with us in this moment and accept us as we are in that moment is a phenomenally intimate, vulnerable thing to do. And it can be incredibly nourishing and doesn’t involve anybody touching anybody.

Lauren Redfern [00:21:56] Absolutely. And I think that’s why I reference it, is to say that, in particular, is that we see them as interrelated and connected, whereas actually they can exist separately. So to be intimate with a partner does not necessarily mean we have to be having sex in this particular way. But I do think that we do tend to see them in this correlated manner.

Dr Claire Macaulay [00:22:15] And they don’t. I absolutely agree with you Lauren. I don’t think they have to be. Now when they come together however, there’s something incredibly phenomenally powerfully, spiritually, however you want to think about it. You know, that can be an amazingly powerful experience, life affirming, all sorts. You know, I often say, ‘I’ve only ever seen God twice, and both times I was having sex.’ So something happens, something that can be extremely profound in that process when they come together, but they don’t have to come together.

Lauren Redfern [00:22:46] Yeah. I mean, I think it’s interesting as well about how we think about ourselves as very static beings as things we think about our desire, our experiences with sex, we think about them in a way where we will be coming back to a particular state of being or a particular state of life that I think our life really moves in seasons and we will have seasons where we feel very sexual and then the seasons where we don’t. And it doesn’t mean that anything is wrong with you if you are going through those different seasons in your life. And it equally doesn’t mean that because you might be in a season where sex is not something that you are interested in currently that you will never be. And I think there is a huge amount of anxiety and pressure around feeling that, you know, we really need to maintain and be having sex in order to fit into that cultural stereotype of an appropriate relationship.

Dr Claire Macaulay [00:23:34] Yeah. And also, I think we tend to be quite static about what we think of as our own sexual expression and what is true for us. And like a lot of things, if you kind of lift the lid on the box and you realise there’s a whole other microcosm of things you just didn’t know anything about?

Lauren Redfern [00:23:47] Absolutely.

Dr Claire Macaulay [00:23:48] I mean, there’s something there about what would it be like if you just explored that? What would it be like to dress up? But often we’ve received these narratives that that’s not OK? You know lets think kink, it doesn’t matter what it is you know, kink, BDSM it doesn’t matter. Somehow that’s weird and all those kind of things but actually what would it be like to dress up? You know, wear high heels and it doesn’t really matter what it is. But actually, what would it be like to just give it a go and see if it’s not for you, it’s not for you, but you’re not going to know unless you try. So there’s something for me when people come to see me is about expanding their repertoire, what they consider to be sexual expression and also bringing in a lot of play, understanding that actually much as sex can become very, very heavy weather for people, particularly if they’re struggling. What would it be like to play? What would it be like to take all of that away and understand it’s just a way to play and express yourself. What would that be like? The three key things that when people come to me and I’m working, we’re working with their body is what is it like to move? What is it like to breathe, and what is it like to make sound? And actually, when you bring those three things together, something special happens in terms of what it’s like to express in this body.

Lauren Redfern [00:24:57] Absolutely. And I think this brings it back a little bit as well to that duality between penetration and our definition of sex. You know that that playfulness could be actually taking the pressure off from meaning that sex needs to end in penetration, that it could just be, you know, even experimenting around, not engaging in penetration for a bit of time to see how that is for you as a couple.

Dr Claire Macaulay [00:25:19] And particularly if people have not been, not had any kind of – because what I see is what happens is we can’t have penetration, so we don’t do anything.

Lauren Redfern [00:25:26] Absolutely.

Dr Claire Macaulay [00:25:26] So you then lose all of the emotional and physiological benefits that we get just from touch alone, so because we can’t have that, we can’t have all of these other things as well. So there’s something made around, you know, what does it mean to bring touch back to your relationship even if that touch is not genital, even if that touch is not focused in a particular direction in terms of orgasm, for example? And what is it like to just experience touch together?

Lauren Redfern [00:25:53] I wanted to ask you, you talk on your website about looking to create sex positive spaces where people feel safe to explore and thrive sexually. And I wondered if you could talk a little bit more about this, as I think it connects to the concept of mental wellbeing that we’ve touched on and sexual pleasure that we’ve touched on. But also how, I suppose both for people in their everyday lives, but also for healthcare professionals. When we talk about sex positive spaces, what we mean by that?

Dr Claire Macaulay [00:26:20] Yeah, I think for me, it really means making room for sex to be OK. Now, it doesn’t necessarily mean people come and take all their clothes off and have sex that’s not really – although it could be that too – but it’s really just about saying, what would it be like if there was nothing here that we need to feel shame about – you know shame and guilt? So they are the two big things that I see people really presenting with when they talk about their sexuality or their sexual expression is that they feel ashamed and they feel guilty about something. And usually that’s because of messages that they’ve received about, you know, what good girls do, often. A sex positive space for me would be somewhere where it is okay to accept that that is a normal part of being a human being and that it’s OK to talk about and express in a way that feels healthy.

Lauren Redfern [00:27:09] I also wanted to very briefly return to the statistic that you mentioned that 70% of those experiencing perimenopause or menopause have problems with their sex life. And I wondered if you had any thoughts, sort of broad thoughts, and suggestions about how we can change this number, how we can make it 70% people enjoying their sex life who are going through perimenopause and menopause.

Dr Claire Macaulay [00:27:33] I think some of it for me is around how we delineate and measure some of these things. So when you look at things like, you know, female sexual dysfunction scores and such things, you know, if you’ve got 30 to 40% of the random population scoring, what a female sexual dysfunction score, that’s not sexual dysfunction, that’s normal sexual female experience is what I would say. So there’s something I think around what the nomenclature is or what we’re expecting, because often what we’re looking at is we’re looking at female sexuality as a slightly wonky version of male sexuality. What would it be like if we actually really knew what female sexuality was about, was the experience and all of those kind of things, and we use that as a benchmark rather than what we have done historically, which is the male centric view of things, is what sexuality should look like, and these female things over here are all just a bit of a broken version of that. So there’s something about some of that. I think what I would really like people who are coming into contact with people at the perimenopausal and menopausal phase of life to understand is one, it’s happening, and two, some of the solutions are really quite straightforward. You know, I think that’s one of the things I think you mentioned in your story about Anna, about vaginal estrogens, for example. They can be life changing for people, fundamentally life changing. The difficulty with them is that we need to start early because once you’ve got both vaginal atrophy, for example, once you’ve lost tissue and all the rest of it, it can be more difficult to get it back and it tends to be a progressive condition. So it’s not that you’re going to treat for six weeks and it’ll be better and you stop the estrogen and it will just come back. It is purely a function of estrogen deficiency. So what I would like to see is people being aware, people offering an understanding that there are very simple treatments that are available that are hugely effective and the earlier we do it, the better the outcome.

Lauren Redfern [00:29:24] I think what’s interesting in Anna story, actually, she goes on to really talk about how exactly that it was using an estrogen based topical in her vagina and around her vulva that made the biggest difference to her experience of pain, that she goes on to discuss how it became difficult to actually obtain Vagifem, obtain the products that she needed to feel that relief from her GP. Because there was also an assumption similarly to HRT. I’ve heard this from women that GP’s will prescribe but only for a short period of time, that you only need it to get through this period. And actually what you then have a large amount of what we’ve talked about today is the mental experience of anxiety. There’s a stress. Am I going to be able to get the products that I need in order to make sex not only tolerable, but desirablefor me as well?

Dr Claire Macaulay [00:30:12] And I think that is one thing that I, from a healthcare professionals point of view, I would like people to really understand this does not go away.

Lauren Redfern [00:30:20] Yes.

Dr Claire Macaulay [00:30:21] We know that the significant proportion of menopausal symptoms is happening in that transition, flushes, all those kinds of things will settle for most people with time. Vulva vaginal atrophy will not, absolutely will not. It is an involution of tissues because they are not being stimulated with estrogen. They are not going to magically grow back without the presence of estrogen, and it can be really real for women. I mean, you know, particularly GP’s will know when you look at a vulva, you know, a de-estrogenised vulva, you know what it looks like.

Lauren Redfern [00:30:51] Yes.

Dr Claire Macaulay [00:30:52] Now, if someone is not bothered about that, if that’s something that is not something that they want in their life or not experience any particular symptoms, then I’m not suggesting that we should routinely give everybody all vaginal estrogens. However, if we don’t ask, then we’re not going to know because we also know that people won’t offer the information. So there is something about understanding that one, earlier treatment is better. Two, people are not going to tell you so you need to ask. And three, if you’re going to start treatment, then it is a treatment that they’re likely to need lifelong.

Lauren Redfern [00:31:24] I think as well, this kind of plays into something quite important, which is not assuming that we reach an age where we don’t want to have sex anymore. You know, I think people continue and should continue having sex into midlife into later life for as long as they want to. And there should not be an assumption based on somebody’s age that they are no longer interested in maintaining a sex life with a partner or themselves, as you’ve mentioned, you know.

Dr Claire Macaulay [00:31:47] Yeah, and deprived of equal importance absolutely. And I think we are beginning to see it because obviously, you know, hanging around in various professional groups where menopause and things is taught you know people – because of the publicity – and it’s becoming a big part of our cultural narrative just now around menopause is older women, you know, in their late 60s and 70s coming to their GP and saying. And good on them, you know, because it is really important. What I would like us to be thinking is let’s make sure women know this when they’re 40, 45, so they ought to be on the lookout for, so that they’re not in the position where they experience significant atrophy of their body. I mean, if you imagine some other part of your body was going to shrivel up and be not able to perform its function. And we had a treatment and people said, I’m going to give you a few weeks to see if that helps. I mean, it just it doesn’t make any sense.

Lauren Redfern [00:32:37] And I know that Louise has talked about this previously as well as there is something interesting about if this were happening to men, we wouldn’t be experiencing, you know, women wouldn’t have…

Dr Claire Macaulay [00:32:47] You know you can have adverts for Viagra on the radio, you can get it anywhere without… You know, but those two things I’m not saying are related, but what I’m saying is the cultural narrative around that. There is a striking disparity I would say, if penises were shriveling up and falling off. We would be having quite a different conversation, I think.

Lauren Redfern [00:33:05] I agree. So I think sadly, that is actually all we have time to discuss today, which is really upsetting for me because honestly, I could talk to you about this topic for hours. Before we finish, however, my big take home from today, I think is this term pleasure explorer. I think, as I’ve said before, everybody should be taking this up to become a pleasure explorer, even if that’s just wandering into a sexual space, a sex shop, a lingerie shop, any way that makes you feel sexy as well, to go and explore that part of yourself. But before we finish, I wondered if you had any final thoughts you wanted to leave us with today.

Dr Claire Macaulay [00:33:39] I think picking up on your pleasure explorer thing, the fundamental thing that I think is helpful with the people that I work with is to believe that it is possible. And that’s why what I do is called ‘The Pleasure Possibility’ because before we can experience anything, we have to believe that it is possible for us and actually, even in people who are listening, take a moment and run the fingers of one hand over the other hand for 10 seconds and go, ‘Does that feel nice? What would make that feel better? Oh, if I do that a little bit more strongly or if I use my fingernails, what does that feel?’ And to understand that pleasure, it is possible for us in every moment, but we have to actually choose. Once we can start to dig into the belief of why don’t I believe pleasure is possible for me and what I internalise about my pleasure as bad or not something I want to achieve? Then we can start to move forward. But it’s about belief that it is possible for you and for anybody that you come into contact with, we’re all capable of pleasure. There is something about how we choose to engage with that.

Lauren Redfern [00:34:40] Absolutely. Thank you so much, Claire. This has been fascinating. And for anybody that is interested in knowing more about the work that Claire is doing, you can visit her website, The Pleasure Possibility, where there’s lots of information about the type of work that you’re doing, the important work that you’re doing. So thank you so much.

Dr Claire Macaulay [00:34:58] Thank you, Lauren.

Lauren Redfern [00:35:02] We would love for you to join our collective of professionals passionate about the menopause. Visit NHMenopauseSociety.org to become an associate, you will receive regular webinars and advice from our experts, as well as opportunities to network and connect with the latest research from around the world. You can follow us on Twitter at @NHMenoSociety. And don’t forget to tell your colleagues about the Newson Health Menopause Society.

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