BONUS: Aging well with Dr Olivia Smart + Nic Beets

Summary

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The Good Sex Project

BONUS: Aging Well with Dr Olivia Smart + Nick Beets

Host: Melody Thomas (PopSock Media)
Experts: Dr Olivia Smart (Obstetrician & Gynaecologist), Nick Beets (Sex & Relationships Therapist)
Date: August 26, 2024

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Overview

This bonus episode delves into the realities of menopause, aging, and changes in sexual health and relationships. Melody Thomas is joined by Dr Olivia Smart, a Christchurch-based gynecologist, who delivers expert insights into menopause and its impact on sexual and overall health, and by Nick Beets, a clinical psychologist and sex therapist, who shares strategies for maintaining intimacy and healthy relationships as we age. Both experts challenge common misconceptions, encourage open communication, and offer practical advice for navigating these life stages.

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Key Discussion Points & Insights

Understanding Menopause: Terms and Timing

[03:18–09:35]

• Transition Phases:
  • Perimenopause is the transition from regular periods to one year after the last period—typically lasting 8 years or more.
  • Menopause is defined as 12 months without a period.
  • Postmenopause is the phase after menopause, bringing its own unique symptoms and challenges.
• Symptom Range:
  • Hot flushes and night sweats are well-known, but estrogen fluctuations affect the whole body:
    • Brain fog, memory loss, anxiety (sometimes severe—e.g., not driving due to anxiety)
    • Heart palpitations, gut changes, changes in fat distribution
    • Profound impact on sleep, stress resilience, and personal wellbeing

"Estrogen depletion or fluctuations in hormone levels can really affect every part of your body."
— Dr Olivia Smart [06:30]

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Why Menopause Symptoms Are Missed

[06:23–09:35]

• Lack of awareness: Many people and some healthcare providers don’t recognize less-common symptoms as menopause-related.
• Objective Tools:
  • The Australasian Menopause Society has a scoring tool (commodified green score) to help users recognize and track symptoms, enabling more tailored interventions.

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Diagnosing Menopause: It’s Not Always About Hormone Tests

[12:27–15:54]

• No Simple Blood Test:
  • Hormone levels fluctuate wildly in perimenopause, so a normal readout doesn't rule anything out.
• Importance of Patient Experience:
  • Listening to women’s symptom narratives is crucial; feeling gaslit by normal test results is unfortunately common.

"If you measure someone's estrogen on a day that it's in the normal range, you ignore all the symptoms that they're telling you. That's when women feel gaslit."
— Dr Olivia Smart [14:10]

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Early Recognition & Diversity in Experience

[16:38–18:02]

• Symptoms can begin as early as late 30s, especially for those with medical interventions (e.g., cancer treatments) or genetic predispositions.
• The average age of menopause is 51, but there’s wide variability.

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Menopause and Sexual Health

[18:02–27:08]

• Genitourinary Changes:
  • Vaginal dryness, recurrent UTIs, discomfort with sex can begin 5–6 years after menopause, when estrogen is consistently low.
  • These symptoms progress without intervention, and are not transient like earlier perimenopause issues.
• Terminology Shift:
  • Now referred to as Genitourinary Syndrome of Menopause (GSM) instead of "atrophy".
• Bodily Changes:
  • Decreased vaginal elasticity
  • Changes in vaginal PH and microbiome (leading to more infections)
  • Loss of natural lubrication

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Relational and Emotional Impact

[23:34–28:58]

• Physical issues often spiral into emotional and relational distance; avoidance of intimacy and breakdown in communication is common.
• Pain leads to fear and avoidance, which exacerbates both the physical and relational challenges.

"It's not just about penetrative intercourse. Women will stop even making eye contact with their partner... because it might spark or instigate something."
— Dr Olivia Smart [25:39]

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Treatments & Practical Solutions

[27:08–33:27]

• Topical Vaginal Estrogen:
  • Creams/pessaries/tablets—preferably applied with a finger rather than the included applicator for better comfort and targeting.
  • Extremely safe, even for many women with a history of breast cancer ([see JAMA study referenced at 31:35]).
  • Alleviates only local symptoms, not systemic (e.g., hot flushes).
• Vaginal Dilators & Sexual Aids:
  • Regular use of penetrative objects (including sex toys or a partner’s penis) can help maintain vaginal elasticity and function.
• Beware of Misinformation:
  • Many package inserts and marketing materials are outdated or misleading, causing unnecessary fear.

"If you want to maintain stretch and capacity with the vagina, put something inside it on a regular basis. It doesn't matter what that is."
— Dr Olivia Smart [33:14]

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Vulva & Vaginal Care Products

[33:46–36:27]

• Avoid soaps and perfumed washes; water or aqueous cream are best for cleaning.
• Oil-based lubricants (like the New Balm co-developed by Dr Smart) are less disruptive to vaginal PH and less likely to cause irritation than many water-based commercial products.

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Shifting to Relationships: Aging, Intimacy, and Teamwork

[39:59–42:33]

Nick Beets joins to address the relational challenges:

• Prevailing Negative Narratives:
  • Menopause and aging are often framed negatively, which can become a self-fulfilling prophecy.
  • Lack of teamwork—often the person experiencing menopause deals with it alone.

"There's so much negative warm up. Change and challenge... brings opportunities for creativity and new learning. And that doesn't get much press."
— Nick Beets [40:25]

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Desire, Arousal, and Shifting Dynamics

[43:19–45:12]

• Redefining Desire:
  • Not feeling instantly "in the mood" is normal. Desire can be responsive, not spontaneous.
  • Open, friendly encouragement and flexibility matter—a clear distinction between lack of desire and lack of consent.

"I make the distinction between feeling like sex... and arousal. No, I want to be sexual. I just don't know how to get there."
— Nick Beets [44:41]

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Empathy, Communication, and Changing Scripts

[45:12–47:26]

• Empathy and genuine interest are crucial; listen and accept a partner’s experience.
• Societal scripts and patterns—especially heteronormative ones—can inhibit more collaborative, flexible approaches.

"If women have not been able to center their own pleasure... then menopause is the perfect excuse to go, okay, I'm done with this."
— Nick Beets [46:45]

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Men, Aging and Sexuality

[50:31–54:28]

• Male partners also experience age-related changes (decreasing testosterone, erectile function).
• Shifting the focus from penetrative sex to a wider sexual repertoire can be liberating for both partners.
• Male self-worth often inappropriately ties to erectile performance, making these changes emotionally charged.

"If your sense of your worth as a man is tied to your erectile functioning, then you're in for a tough time, if you're lucky enough to age."
— Nick Beets [52:46]

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Facing Change: Strategies and Opportunities

[48:18–50:05], [55:03–63:45]

• Adaptation: Being open to changing approaches to sex and intimacy. Sometimes taking things slower, sometimes using additional aids or alternative activities.
• Conversation Tips:
  • Be aware of your own narratives and avoid making things about personal rejection.
  • Make space for a real conversation, grounded in curiosity and compassion, not problem-solving immediately.
  • Focus on finding new ways for pleasure together, not just "increasing frequency".

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Notable Quotes & Memorable Moments

• "There's this consistent finding... of people having the best sex of their lives in their later life. And clearly it is not... terribly athletic and... defocusing on penetrative sex."
  — Nick Beets [51:50]

• "Whenever there is change, there is loss. And wherever there's loss, there's grief... but they are also opportunities."
  — Nick Beets [50:33]

• "[Men] wanting to get to penetrative intercourse really quickly because they don't trust that their erection is going to be sustained... their partner's going in the opposite direction where their arousal is slower."
  — Nick Beets [62:00]

• "It's a privilege to get [to old age]... Catastrophizing doesn't just happen around menopause and loss of erection. It just happens around aging."
  — Melody Thomas [59:26]

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Timestamps for Key Segments

• 03:18: Intro to Dr Olivia Smart, overview of menopause terminology and experience
• 06:30: Symptom complexity and body-wide changes
• 12:27: The limits of diagnostic hormone testing
• 18:02: Sexual health symptoms post-menopause
• 25:39: The emotional and relationship spiral due to pain and avoidance
• 27:08: Treatments—local estrogen, lubricants, vaginal care
• 39:59: Transition to relationship/psychology with Nick Beets
• 43:47: Changes in desire, reconciling consent and sexual willingness
• 46:45: Gender dynamics, male partners’ experiences, and liberation narratives
• 50:31: Aging men, shared vulnerabilities, and expanding sexual scripts
• 57:10: Communication strategies for couples
• 62:00: Clashing sexual scripts and mutual anxieties
• 63:45: Wrap-up and key takeaways

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Takeaways

• Menopause symptoms are vast, often misunderstood, and require attentive, holistic care.
• Sexual health and pleasure are still very much possible—and sometimes better—post-menopause with the right strategies and openness.
• Shared empathy, creative adaptation, and open, nonjudgmental communication are essential for couples facing these changes.
• Both women and men experience profound bodily changes with age; teaming up against the challenges can transform the experience.
• Aging is a privilege, and with the right approach, can bring freedom and deeper intimacy.

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Resources Referenced

• Australasian Menopause Society – Symptom Scoring Tools
• New Intimate Balm (New Balm) – Oil-based personal lubricant developed in NZ
• Journal of the American Medical Association Study on vaginal estrogen and breast cancer

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Final Words

For anyone navigating menopause or aging, this episode offers reassurance, expert advice, and a compelling reframing of later-life sexuality—not as loss, but as opportunity for new intimacy and self-connection. Take these strategies to heart and keep the conversation going, for yourself and your relationships.

Transcript

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[Melody Thomas]

Kia Ora.

And welcome to this bonus episode of the Good Sex Project. I'm Melody Thomas and we are here to expand on our conversation about menopause from episode eight with Christchurch based obstetrician, gynaecologist, Dr. Olivia Smart, and sex and relationships therapist and author of the book Make Love Work, Nick Bates. We're kicking things off with Olivia Smart, who brings so much knowledge and experience in women's healthcare, particularly in the fields of menopause, perimenopause, post menopause and sexual health. In our conversation, we're going to delve deeper into the ways that hormonal changes can affect the body. We will myth bust some common misconceptions and explore effective treatments and strategies for managing the symptoms of menopause. I started our interview by asking Olivia what drew her into women's healthcare and specifically to gynaecology.

[Dr. Olivia Smart]

I didn't really like looking after sick people when I graduated from medical school and I think that not everyone's equipped to meet that challenge. And many of the women that come to me are either completely healthy, for example, during pregnancy, or have a problem that's quite easily fixed and you can return them to full functioning in all their capacities, be it as a mum or carer or a worker or a CEO of a business. And that's really rewarding.

[Melody Thomas]

I imagine that there's people listening because we are going to talk about some of the side effects of things like menopause and perimenopause and to hear you say, you know, some of these things are fairly easily treatable, I just feel like there must be people listening, going, what?

[Dr. Olivia Smart]

Well, I think for any of us can identify with being in a difficult patch, be it with physical health or mental health, and on any given day thinking you're going to feel like that forever and not being able to see beyond that. So to have insight a. To recognize what's going on with you, I think half the battle is recognizing that that is the issue. And you may not be aware yourself of what's happening to your body, or you may go to a healthcare provider or reach out to someone and be sent off in the wrong direction. So I think that the first part is increasing awareness and I think that's really happening at the moment. It's super encouraging that these conversations are opening up and I think that women are kind of getting on the bandwagon about being proactive with a lot of these issues.

[Melody Thomas]

So what are some of the early symptoms and why does it take so long for them to be recognised is what they are?

[Dr. Olivia Smart]

There's a lot of Confusion around terminology, perimenopause, menopause, and post menopause. And I think it's worth clearing that up because, again, it's like women go, oh, okay, I get it now. It is a journey. That's a bit of a euphemistic term. But the transition from you having regular ovulating every month, having a regular cycle, to having no periods and your last period is what is considered menopause. So you don't know until you haven't had a period for 12 months that it's definitely stopped. So that transition from regular periods to last period is perimenopause. And it can be, on average, eight years. And it can be symptomatic or it can be asymptomatic. And there are lots of women that say, well, my periods just stopped. And that was that. Didn't even realize. And then there are women that have a very long transition phase, and it's only when they look back and go, oh, I think I've been having these problems since my early 40s, but I didn't recognize it till I was into my 50s, when my periods then stopped. Anything beyond that is post menopause. It has different challenges. It has different symptoms. I think that the time that gives women the most difficulty is perimenopause. And why is that, I think, was the question, because we all perhaps are familiar with common symptoms. Mood, I'm going to kill my husband, hot flushes, throwing off the bed clothes, getting very hot. But those are only two of lots and lots of symptoms that can occur. And there's a big overlap with other health issues. So you have to know that it's not only hot flushes and night sweats, but that estrogen depletion or fluctuations in hormone levels can really affect every part of your body. So if we work sort of from the top down, you can get brain fog, cognitive issues, memory recall, word finding. You can get severe anxiety. I've had a woman who didn't drive a car for about a year. She had this overwhelming anxiety every time she got in her vehicle. That stopped her from driving. And it wasn't until she got her hormonal balance back in check that she was able to look back and go, oh, my goodness, this was nothing to do with me losing my marbles or getting old. This was purely hormonally driven.

[Melody Thomas]

But there's no way you would start to feel anxiety over getting in the car and be like, oh, it must be menopause time.

[Dr. Olivia Smart]

Unfortunately, at the moment, no. But this is what we want to change. And so then we work down. You can get heart palpitations, cardiac changes, changes in your gut, your gut microbiome changes completely. So you may find that you can't eat the foods that you were eating before, drink the wine that you used to, you can't drink the wine that you used to. And that's a real. Well, that's a good one. That's your body telling you enough is enough. Changes in distribution of fat adipose around the body. And then a lot of what we're going to talk about today is changes in the pelvic area. It's subtle and the symptoms develop slowly and you just keep on keeping on, don't we? In our society, women are the copers. We take more and more and more on board and we don't realise how far we've slid from feeling normal or feeling well or thriving, you know, often until it's too late. You might not be sleeping well, we might be stressed around work. The teenagers will be causing you to pull your hair out. You might have a parent that's ill or aging or needs to go into hospital. We're juggling all these things. What's the first thing that falls off the radar is our self care and looking after our own well being. But yeah, these are all things that can influence how we feel. So how do you work out what's going on for you? There are some objective tools that you can use. The one that I use with my patients is from the Australasian menopause website. It's called the commodified green score and it gives you a range of symptoms that could be attributed to menopause and you score them from 0 to 3 and you get a score at the end. And obviously that is not definitive. What we're looking for is shifts and then you adopt different strategies and you see whether your scoring changes. So you might adopt some sleep hygiene, you might want to try some cognitive behavioral strategies, you might want to try some hormonal treatment or you might want to try some non hormonal alternatives for menopause. And then you go back and rescore at three months and see, has anything changed? Have there been any improvements? Particularly in the area where you're scoring highest with any wellbeing approach, you've got to try it, see if it makes a difference. And if it doesn't, then you've ticked that box and you've looked at it and you may want to revisit it a couple of years later. If you don't feel significantly Better. It may not be a hormonal issue.

[Melody Thomas]

In terms of diagnostics, can you physically test somebody and say your estrogen is low? This is menopause?

[Dr. Olivia Smart]

The simple answer is no. There may be situations where measuring oestrogen levels is useful, but in that menopause transition from regular periods through to last period, your estrogen and progesterone levels fluctuate a bit. Like if your car, you've got a bit of a knackered old car and the motor's starting to give out a bit and you need to accelerate, so you put your foot on the accelerator and then it does a big surge in power. The same's happening within our bodies. There's a regulatory center in the brain called the hypothalamus. And it detects when the ovaries are starting to flag a bit, when the production of hormones isn't as efficient. And it sends a signal through to the pituitary gland to release stimulating hormones, LH and fsh. And those in turn give the ovary a big turbocharge. And then we see estrogen levels going super high, and then they gradually dwindled back down. And then the same thing happens again in no real pattern. And so that varies hugely from the more stable and predictable hormonal fluctuations that happen throughout our reproductive lifetime. If you measure someone's estrogen on a day that it's in inverted quote commas in the normal range, you ignore all the symptoms that they're telling you. That's when women feel gaslit, that's when they feel unheard because they're going to a health practitioner or health provider and saying, I feel terrible. I'm getting all these symptoms. Could it be menopause? If you then have someone come back to say, no, your estrogen levels are normal.

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[Dr. Olivia Smart]

You must be depressed. This is when you know women feel unheard. You can still be having regular periods, you can still have measured normal estrogen levels, and you can still definitely be in perimenopause. So the only way is to adopt strategies that may help to help your body. And those could be lifestyle, they could be hormonal and then see what makes you feel better. But it's definitely not a hard and fast science. So the first thing we have to do is be open to listening to women's symptoms and acting accordingly in terms

[Melody Thomas]

of age range and in terms of symptoms. At what point should somebody be stopping to think, is this something I should be exploring? Should I be going and filling out that survey?

[Dr. Olivia Smart]

Any age?

[Melody Thomas]

Because I think a lot of people

will go, oh, I'm only 35, I'm only 40.

[Dr. Olivia Smart]

So a couple of things. Average age of menopause is 51. Commonest age range would be 40 to 60. But really, anyone can get symptoms. Menopause transition can take eight to 10 years. So anyone in their 40s, definitely. But some people experience their last period at 42, and if their transition has been 10 years leading up to that, they may experience symptoms in their 30s. Then you've got other factors that play in. So there may be genetic factors that mean your ovaries are not programmed to ovulate until you're 50. You may have only got 10 years programming in your ovaries, and we call that premature ovarian failure. So that's a specific group of women who will need help a lot sooner. Cancer treatments will often cause your ovaries to stop functioning or surgery for whatever reason.

[Melody Thomas]

Yeah. So let's dive into some of the specific symptoms related to sexual function and sexual health that you see commonly in your practice.

[Dr. Olivia Smart]

If we can begin at the level of how menopause affects the genital region, and then what are the impacts on sexual functioning? That's an area that I think is really under discussed. And one of the things that I noticed in my practice was that three, four times a week women would be coming with symptoms. I would explain the menopausal changes that were happening and what we would do about it and would consistently hear this messaging of, I had no idea that this was a menopause problem. Because what we see is all the symptoms that we've talked about already. Once they've settled down and you see this bottoming out of estrogen to a steady state, but low postmenopausal level, a lot of those symptoms will go away and women will get this sense of relief that I'm done with all that nonsense. I'm feeling myself again, I'm through menopause, and I can put it all behind me and get on with life. But that's the point that we start often to see changes in the genital region, vulva, vagina, urethra, bladder, because all of those tissues are packed with estrogen receptors and they start to cause symptoms once your estrogen levels are consistently low. And those symptoms, unlike the transient symptoms of perimenopause, the genital issues start at that point, usually about five to six years after your last period. So we're now looking at that group of women who are sort of 55 to 60, and they get steadily worse with time, unless you address them.

[Melody Thomas]

So to these women, menopause was ages ago.

[Dr. Olivia Smart]

Absolutely. Now suddenly I'm getting vaginal dryness. Sex isn't as comfortable. I keep getting UTIs, getting a bit of discharge.

[Melody Thomas]

Now.

[Dr. Olivia Smart]

My walking group aren't talking about this. My book club aren't talking about this. I certainly am not going to talk about it to my husband. I didn't know that this was a problem. The collective term for those symptoms is. Is a complete mouthful. It's genitourinary syndrome of menopause, or gsm. We're trying to get rid of the previously used word atrophy, which is a horrible word. And there's lots of changes with our body, with aging that we should embrace no matter whether they're welcome or not. There is atrophy all over. And men and women, I bet there's no term penile atrophy out there, but I bet your bottom dollar that it happens.

[Melody Thomas]

So what are some of those bodily changes?

[Dr. Olivia Smart]

Elasticity and blood flow in the skin and the vagina will become shorter. And in reproductive life, it has these beautiful folds that increase elasticity that help with intercourse and childbirth. And we lose those elastic folds in the vagina, so it's less stretchy. We see changes in the shape and size of the entrance of the vagina and the labia and the entrance to the urethra. So there's anatomical changes that occur, and then there's blood flow Changes that occur. And blood flow relates also to how much natural lubrication that you have inside the vagina. Then you get changes at the cellular level with how much glycogen are in the epidermal cells that line the vagina. And glycogen feeds the good bacteria or the lactobacillus in our vagina. When you get fewer lactobacilli, your PH in the vagina goes up, so becomes more alkaline. And in an alkaline environment, other organisms thrive, like E. Coli. We have a group of women who will say, oh, I don't have a dry vagina, but what I've noticed is I've got all this discharge, but don't recognize that the discharge is a manifestation of menopausal changes that are happening in the vaginal skin. There are changes happening in the uterus and endometrial lining. They're usually good. Your endometrial lining should stop bleeding and your uterus becomes smaller. So if you ever had, if you've had any problems with periods or any of the multitude of problems that can go along with reproductive life, like endometriosis or, or fibroids, they get better. That's a tick.

[Melody Thomas]

Yay.

I know.

You could see the droid in my face, so thank you for giving me that. When it comes to the muscle and pelvic support, which in a lot of people would have already been compromised by childbirth, is this when you might see a prolapse?

[Dr. Olivia Smart]

So definitely two groups of people. We work really closely in women's health with women's health physios to help work out a strategy for, for you. The interesting thing is that as well as pelvic floor muscle weakness, which can contribute to prolapse alongside actual physical trauma to the supporting structures of the pelvic organs, they also deal with a whole group of women who have inflexibility or tightness in the pelvic floor complex, which can be as debilitating as having a weak pelvic floor. So that's often where our physios will come in and work alongside some of the other treatments that we'll probably go on to discuss. For menopausal changes, all our tissues change with age. And that can be more marked in some women than others. The earlier you recognize symptoms and the earlier you engage in treatment, the less likely they are to progress to a point of no return. Because as well as the physical manifestations, it's the wider ramifications of how that impacts on self esteem, on relationship, and then on Intimacy because it's very easy to get into that pain. Pain causing fear or anxiety, anxiety causing decreased arousal, decreased arousal causing lack of lubrication, lack of lubrication causing more pain, and then avoiding any intimate contact. And what I hear, and I'm sure you probably hear as well, it's not just about penetrative intercourse. Women will stop even making eye contact with their partner or sitting too close to them on the sofa in the evening because it might spark or instigate something that they don't. So, you know, the breakdown in relationship is huge. And then I suspect many couples will not want to have that conversation or have the tools to have that conversation. So over here on this side of the sofa, she doesn't know what's happening with the changes in evolva and why it's painful and what's going on and what she can do about it. And is she the only person that's suffering this issue, or is everyone having that problem and he's sitting on his side of the sofa thinking, well, she obviously doesn't love me anymore. And, you know, they're in their own world of pain, and then there's this big chasm in between, this big void that's just going to get wider and wider and wider.

[Melody Thomas]

Can we talk more specifically about some of those symptoms? You know, we talk about pain and discomfort. Is that specific to attempted penetration? Is the dryness just. Penetration is difficult because there's no lubrication, or is it something that you would

feel as you go about your day?

[Dr. Olivia Smart]

I think it depends on the severity of symptoms. The tissues around the entrance to the vagina are super sensitive. Generally what women will recognize first is probably just discomfort with penetration. They're able to achieve penetration, but it may feel a little bit dry. Sandpaper's the term that often gets brought up. So they may not find arousal as easy again due to decreased blood flow. And pain with penetration tends to be the symptom that stops people having penetrative intercourse. Now, there can be other reasons why you've got pain with penetration. So it's important, important to understand that there may be other factors influencing that, and also important to acknowledge that penetrative sex may not be the be all and end all, and that you can have a fully satisfying sex life without having penetrative intercourse. So you may be happy within your couple just to transition or to change or to adapt. But the issue that we want to address is for those women who want to maintain penetrative activity as part of their relationship, and it's become painful. And it's at a time when we think that we would anticipate that low estrogen levels was the issue. Know that there's a very easy solution to the problem and that is Lupre. Well, I think probably the number one treatment is replacing oestrogen in the vagina and vulva with local topical oestrogen treatment.

[Melody Thomas]

These are the creams with the little syringy thing?

[Dr. Olivia Smart]

Yes. I generally tell women to throw away the syringey thing. They are uncomfortable, they're inflexible, often have little scratchy edges on them that cause pain. And they tend to design. And the information leaflet says this as well. Deliver the cream high into the vagina. But if you've got pain on penetration, you need estrogen around the entrance to the vagina. If you've got UTIs, you probably need estrogen around the bladder neck. So I generally say a finger's a much better applicator and you can just easily wash it afterwards. Whereas the cream applicators you have to get in the little grooves around the top of the applicator, then you have to leave it next to your toothbrush. There may be some women who, for whatever reason, if you've got severe arthritis or you particularly need for you, you need estrogen up by the cervix and there may be specific reasons why that might be happening. In that situation, an applicator may be useful, but for the vast majority, using your clean finger is perfectly adequate. So topical oestrogen therapy. I think like all estrogen therapy, there's a lot of fear and scaremongering around use of it and we really have to get the message across that low dose estrogen applied as a cream, pessary or tablet into the vagina doesn't raise whole body hormone levels in the same way that standard HRT does. So if you're using estrogen therapy into the vagina, you're not going to get rid of your hot flushes, night sweats, all those things need a tablet or a patch or a gel. If you're just using it in the vagina, you will only treat vaginal symptoms. It's super, super, super safe. It's really easy to use and it will often be effective within a couple of weeks and help reduce some of those multitude of symptoms, particularly pain with intercourse. There was a big paper published at the end of last year in the Journal of the American Medical association that studied women who'd had breast cancer, 50,000 women who'd had breast cancer, and those that used vaginal Estrogen had no greater rates of all cause or breast cancer related mortality than those who hadn't. So we've even got data now that shows women who've had suffered with breast cancer can and should be potentially using vaginal estrogen for those symptoms. Unfortunately, when you are prescribed one of these treatments, if you pull out the information leaflet in the packaging, it will tell you don't use it. If you've had breast cancer, don't use it can cause breast cancer. So there's a lot of misinformation.

[Melody Thomas]

Why is it in the information page?

[Dr. Olivia Smart]

I suspect it's all FDA regulations, black box warning. The manufacturers are put under certain regulations and there's been a big push particularly through the states to try and address that, trying to explain the harm that it's doing. One of the treatments that we often will provide them often not very well with, but is a set of vaginal dilators. So that's using a device or often penis shaped, you know, cylindrical to maintain stretching capacity in the vagina. Penis is a very good dilator. So if you want to maintain stretch and capacity with the vagina, put something inside it on a regular basis. It doesn't matter what that is. But a bit like a penis will work as good as anything else.

[Melody Thomas]

The dildo will work.

[Dr. Olivia Smart]

Yes. As we do wrap up, I guess

[Melody Thomas]

a natural point to finish on for me is just any final advice or takeaways or something speaking directly to listeners who maybe have felt had suspected something was going on and weren't sure what to do about that.

[Dr. Olivia Smart]

I think that the most important thing is to seek advice from your healthcare practitioner. If you feel comfortable, talk to your partner or friends. For women to. I think one of the things that I think is a minefield is this Generation M and the marketing of all sorts of different nonsense to women that may or may not be useful to them. For the most part I think I see everyone jumping on the bandwagon. Vulval hygiene products, anything to do with cleansing, deodorizing, making your vulva or vagina cleaner, cleaner, prettier, more like a Barbie doll. Yes, all of that nonsense. You don't need soap on the genital region, obviously if it doesn't irritate your skin to use it in the external area, that's fine. But even those soap free alternatives, I won't name names, but we all know which ones are promoted. Have a look on the back. Have a look at how many chemicals are in those sorts of products. If you've got sensitive skin and generally beyond menopause the skin does become more easily irritated, more sensitive. Avoid them, just use water. You can use aqueous cream as a soap substitute that you can buy from your pharmacist or get your GP to prescribe. You definitely don't need anything inside the vagina. If you have an odorous discharge, it may be that there is some form of a bacterial imbalance or a yeast infection, or you may have menopausal low estrogen changes that are altering the ph and the bacterial colonization in the vagina. So that may respond to estrogen and then with sexual activity using preferably an oil based lubricant that doesn't interfere with your natural ph and doesn't affect the osmolarity in the vagina. Because a lot of the over the counter water based products will actually suck water out of the vagina by osmosis and leave you with an altered ph and with more dryness afterwards, more irritation. That just keeps that vicious cycle going.

[Melody Thomas]

Tell me before we finish about Nuval then.

[Dr. Olivia Smart]

So when we work alongside health physios, we're often encouraging women to use an oil based lubricant and we didn't have a product available in New Zealand. So Niamh, the physio that I work alongside, suggested that rather than importing a product from Australia or the States, that we could produce our very own oil based lubricant from our very own bees and olives here in Aotearoa. So that was the idea behind New Balm. But for me as a gynecologist I wanted to be able to provide a reliable platform where women can go so not only are getting the product but you can then go to the website or social media channels and get some reliable information and start to normalize the topic of conversation and share it with girlfriends. So that was my passion and still is the the passion behind it and hopefully we will be able to increase awareness and thank you to you for inviting me on this podcast today to keep that conversation going and hopefully, you know, if we can get one more person to feel comfortable talking about the topic and sharing with their friends, relatives or going to see their doctor about it, then that will be another tick.

[Melody Thomas]

Thank you so much Olivia. That's Dr. Olivia Smart, Otahi based obstetrician, gynaecologist and co founder of New Intimate Balm.

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[Melody Thomas]

It's time now to turn our focus towards the relationship side of things, to how relationships can be affected by the changes of menopause as well as other bodily changes that happen with age to men and how we can face those things as a team in order to maintain a happy and healthy relationship. And if it's what you want, a happy and healthy sex life. Joining me is clinical psychologist and sex therapist Nick Bates.

[Nick Bates]

There's a lot of really negative talk about menopause and about change around our bodies and around sexuality in general. And I think it's really sad that there's so much negative warm up. It's like change and challenge to the way you have always done things brings with it opportunities for creativity and new learning. And that doesn't get much press when

[Melody Thomas]

you're setting yourself up for it to be really horrible and really hard. Like on the one hand you're preparing yourself for difficulties that may in fact be heading your way. But you, I imagine there's some kind of a self fulfilling prophecy dynamic that could also step in there.

[Nick Bates]

Yeah, well it certainly can. I mean we can certainly talk ourselves into a negative state of mind. There's no, there's no question about that. And I think also What I see in couples and hetero couples that I'm working with around this is that there's often not been a good sense of team around the impact of hormones and things like that. That's been an ongoing issue in the relationship. And typically the women have had to deal with it very much on their own and not had a lot of interest or support from their partners. So when we get to this big change, there isn't that sense of collegiality or friendship or support around that issue. And so, you know, the, the, the people who are, who are dealing with the changes in their body don't, don't feel understood or supported. And I think that also really adds insult to injury. It's kind of like it's already difficult enough. And then it seemed like I have a problem or I am the problem because my body is changing rather than, here's a challenge that's coming to us, to our relationship, to our sexual relationship. How are we going to deal with it? Very different attitude.

[Melody Thomas]

So I imagine that through your mahi, you see a few couples that are struggling with the changes around this time. And I'm curious to know what some of the kind of specific challenges are that people are facing during this time.

[Nick Bates]

It's very often there's a, there's a, you know, there's a change in the person who's going through menopause and kind of what it means to them. And, and very often if we, if we're focusing specifically on the, on the sexual side of things, there is a real change in the way that they feel about their bodies, but also about the way they get to being sexual. So so often a change in, in hormones will, you know, will impact that, and that's seen as a threat or, you know, a loss by their partner. And so you've got one person who's kind of struggling and having a difficult time, and then their partner is caught up in what does this mean for me. And often, as we were saying, you know, the stories are really negative, are catastrophic.

[Melody Thomas]

Oh, my God, our sex life's over forever.

[Nick Bates]

That's the, that's the narrative. You know, that's the narrative. And I mean, that is the case in some couples, but usually there's a, you know, there are more complicated reasons as to why sex ends just rather than just menopause.

[Melody Thomas]

So in terms of the desire in getting to arousal, that's potentially people who found that more spontaneous and easy now have difficulty, more difficulty getting over that, that first hump to getting in the mood.

[Nick Bates]

Absolutely And I mean, even that notion of being in the mood, it's kind of like the assumption that that's what you have to do in order to be sexual. And it's like, well, that assumption isn't going to work for a whole bunch of people. I mean, it's not going to work for some people before menopause, but a large group of people, that's not going to be the way they get being sexual. They're not going to feel like sex. That doesn't mean you can't be sexual if you want to be.

[Melody Thomas]

When we talk about how someone might not be, like, necessarily in the mood feeling like they want sex, I feel like some people might hear this and be like, well, they don't want sex. So this is a consent thing. We just. No means no. But I just wanted to say I feel like what we're actually talking about here is a situation I've been in where I'm like, oh, I'm not really feeling it. And then my partner is like, well, how about now? Are you feeling it? If this is happening and, you know, like, there's a friendly encouragement and suddenly I'm all on board. This is what we're talking about.

[Nick Bates]

Yeah. And I make the distinction between feeling like sex, which is like, yeah, I don't feel like it now. I'm not horny, I'm not turned on. I'm not experiencing sexual desire or little. And arousal. So that's not feeling like it. But in my head, I want to be sexual or I want to have a sex I want to have.

[Melody Thomas]

I want to get there.

[Nick Bates]

I want to get there. I want that to be part of our relationship. So. And that's, for me, where the consent piece comes in. So it's kind of like, no, I want to be sexual. I just don't know how to get there. So the consent is very freely given.

[Melody Thomas]

What role does empathy play in all of this? How can a partner who's not the partner experiencing this lean into that empathy and understanding?

[Nick Bates]

I mean, empathy is critical to us working together, particularly when we're dealing with difference. Right. If you're a man and you have a partner who's having. Whose hormones are having a big impact on them. I mean, you know, show interest. Like, it's very different than, you know, the average male experience. Although, don't forget, all males went through puberty. So we actually have had, you know, we have some knowledge if we. And, you know, if a distant memory of being at the mercy of our hormones and kind of how out of control you feel. So I don't think it just clicked for me.

[Melody Thomas]

Sorry. That the hot flush is like the older female equivalent of the unwanted boner on the bus.

[Nick Bates]

Yes. I mean, yes, absolutely. Yes. I suppose so.

[Melody Thomas]

Not now.

[Nick Bates]

Yeah, yeah, not now. I do not need this now. Absolutely, absolutely. Yeah. And, you know, and, you know, you know, your mood not being under your control, it's not that men have no basis for connection and I think, but it's that thing of being able to just, you know, listen to what your partner's experience is and show interest in care and just accept their experience as their experience.

[Melody Thomas]

So do you have, through your experience, any ideas about why sex, for some people, for some women going through menopause becomes just like a no interest or don't want for those that don't want to.

[Nick Bates]

Yeah. I mean, so often women have been having sex that's very oriented around the needs of their male partner. Unfortunately, that's just still a, you know, a really strong reality. And you've talked about it, you know, in previous episodes and, you know, if women have not been able to center their own pleasure through the course of their sex lives, and particularly with, you know, one. One partner and they've settled into something that works okay for them but is not really about them, then menopause is the perfect, perfect excuse to kind of go, okay, I'm done with this, you know, I'm done. And now that that long history of frustration and resentment and a lack of care comes out to play, I just

[Melody Thomas]

imagine that around this time, a lot of things, not just sex, come up for a reassessment. Has this serving me, I don't have patience for this anymore. That's gone. Yeah.

[Nick Bates]

Yeah. And I mean, it's, you know, it can be a time of real liberation for women who are kind of have stepped out of that, you know, being depended upon role that, you know, where they felt like they've had to put their own needs to one side and really, you know, step into their power often, and that's, you know, great for them. But if the relationship has not had room for that previously, then, you know, sometimes the relationship can't adapt to that.

[Melody Thomas]

So I guess I'm wondering, you know, if we were to look at this change through that lens, what. How do we need to approach it? What are our strategies for embracing the change and what gifts might come from that?

[Nick Bates]

I think there are, you know, there are. There are two things. One is to remember that although perimenopause and menopause can go on for years. It is, you know, like it's. It's. It is temporary. Like it is. It. It is a phase in a stage. So the, you know, there is a new norm. You know, as long as you're lucky enough to live long enough, there is a new norm out the other side is because I think one of the things about that period of hormonal fluctuation is you never quite know what you're getting from day to day. And I think that's very disconcerting. So I think when you're being hit by strong hormonal fluctuations, either in perimenopause or menopause, you've got to be adaptable. So I think there's that kind of adaptation. I think then in the bigger picture, it's working out okay. So how does my body work now, and how do I want to get to being sexual? What works best for me? And as you mentioned earlier, so often there is a real change in that initial phase of arousal. It just seems much harder to get into a sexual wavelength. And so how you go about the. The initial phases of sex often really needs to change. Sometimes it's about, you know, taking things more slowly. Sometimes it's things like adding in. Adding in a vibrator that really gives you a really big, big initial push of, you know, physical stimulation to help get, Get. Get you in the kind of headspace.

[Melody Thomas]

Yeah.

[Nick Bates]

So, you know, again, it's all very personal. You've got to work out what works, you know, for you and your body. And then, of course, if you're having partnered sex, your partner's got to be on board with that and not feel like somehow they're having things taken away or being threatened or whatever.

[Melody Thomas]

Once you're kind of over that initial hump and you're. We're all on board with what's happening, there's probably also some flexibility to bring into play there, because if you have vaginal dryness or you have discomfort, then penetrative sex might just not be something that you're into that into for a while, which, again, will feel like a potential loss. And that's okay to grieve that, but also opens up that whole kind of buffet of other. Other things. And. Yeah, like just.

[Nick Bates]

Absolutely.

[Melody Thomas]

I mean, for a while.

[Nick Bates]

Whenever there is change, there is loss. And wherever there's loss, there's grief. Whenever our life changes, our body changes. For whatever reason, we may feel sad about them, but they are also opportunities. And certainly as, you know, as people age, often there is a move away from penetrative sex, that as bodies change, I mean, don't forget male bodies do change as well, and not as rapidly, but male hormones are decreasing. Testosterone is decreasing 1% a year, every year from 30 or 40, depending on who you talk to. So men are experiencing hormonal change as well. And certainly by the time you get into your 60s, like me, you know, you're very aware that, you know, your body's working differently and, you know, your erectile functioning, you know, on average is, is, Is not what it was. You know, the pump system, the vascular system does, you know, get tired. So, you know, the move away from penetrative sex actually can be a real boon to men who are aging as well. If you take that focus off penis and vagina intercourse, then you start explore the other enormous smorgasbord of options available to you. And I mean, there's a whole bunch of research about people in there, 50s, 60s, 70s and older. And there is this consistent finding across multiple studies across the world of people having the best sex of their lives in their later life. And clearly it is not, you know, it is not, you know, terribly athletic and, you know, and very often there is a defocusing on penetrative sex.

[Melody Thomas]

I, you know, as much as that is, you know, potentially offers some relief to male partners that the move away from penetrative sex could benefit you. If your vascular function is getting more tired. There's also, you know, a real tie in between sense of self as men and ability to maintain and get, get and maintain an erection. So while it might be a relief, again, there's probably going to be a little bit of processing involved there. Right?

[Nick Bates]

Look, absolutely. I mean, the way I was talking about is kind of an idealized way, or it's a way that you talk about it. If you're a sex therapist and you've had all the vicarious learning that you have like that I have, you know, we linguistically do this thing where we use the word manhood as a, you know, as a synonym for penis or erection. And that's really probably. I mean, you know, that points to a really problematic sense of identity for men. If your sense of your worth as a, you know, as a, as a man is tied to your erectile functioning, then you're, you're in for a tough time. If you're lucky enough to age, because that, you know, it isn't going to work the way it did when you were 20 and the expectation that you should continue to have sex the way you did when you were 20 or 30. Is, is, you know, is really unhelpful and puts a whole lot of pressure on men. And, you know, there is real grief. And in many ways it's like those men who, who had, you know, who had very reliable erectile functioning early on in their lives are often the most badly affected because they've kind of felt like, had a really, you know, whereas a really sort of reliable penis. And, you know, those who maybe had difficulties earlier on are more open to, okay, well, this, you know, erectile functioning comes and goes and that's a normal part of life, which it is. But not all men kind of have their head around that. If you can, can step away from that, you know, that fusion of your identity with, you know, the functioning of a particular part of your body, then you can really be much more creative in how you approach sex.

[Melody Thomas]

It's so bloody reductive, isn't it?

[Nick Bates]

And I think particularly so in male culture and in the way men talk about it, in the way men are depicted in porn or indeed even in rom coms. Men are always up for it. Men are always ready. Men can help have sex at the drop of a hat. And if you, you know, if you're into somebody, then you're going to have a reliable erection. And that narrative is, you know, very pervasive and very hard for men to kind of think differently than that.

[Melody Thomas]

And I can see it working both ways. So with, say, a male partner who is struggling with erection and potentially with some, a female partner who's going through menopause on both sides of that, I feel like the other partner could. There's the potential for it to be this. This to be seen as a rejection.

[Nick Bates]

Oh, totally, totally. So many of us fall into the trap of looking at our partner's sexual attraction to us as an important plank of, you know, proof of our attractiveness or our worth. And that is, you know, that is problematic because actually, you know, whether our partner feels like having sex with often has a lot, I mean, a lot to do with what's going on with them. So, you know, it's. It's getting outside of that and realizing actually I look to sex to prop up my sense of self. I look, look to sex for reassurance. And actually I need to learn to do that for myself and not rely on my partner to make me feel okay about myself. And that's a big learning that many people do not make in their relationships. And, you know, a lot of people, they feel, you know, rejected by their partner. And I mean, you know, being, being you know, your partner saying no to you, no to sex with you is not them rejecting you. That's them saying, I don't feel like sex at this point in time. That's what they're saying. They're not saying, I reject you. But so many of us turn it into that story and then, you know, then we feel bad and, you know, often we might get resentful towards our partner for making us feel that way and the whole thing, you know, the whole, the whole scenario around our sex life spirals down.

[Melody Thomas]

Okay, so if some of these struggles are familiar to people listening and they haven't been able to necessarily find a way into conversations about it yet, have you got any tips for how to broach the subject and how to get yourself in the head space to do that conversation? Right.

[Nick Bates]

I certainly think sort of continuing on from the last point, it's kind of like you've got to look at yourself and go, what story am I telling myself about my partner's struggle to get to being sexual? And am I, am I making it a thing about, you know, the, the, about me? Am I making it that they don't want me or that my, you know, my sex life is over? Or am I telling myself a really negative story and really interrogate that and try and catch, you know, am I doing that? And, you know, if you haven't been doing it, then, you know, back to inquiring into your partner's experience, you know, with, with, with genuine interest, genuine curiosity and genuine care. It's like, hey, I've really noticed that, you know, we haven't been having anything like as much sex as we were, you know, a couple of years ago. You know, I'm worried about it. I would like there to be more, but I'm, you know, I'm really aware that you're struggling with stuff and, you know, you've said that it's not that you don't want sex, it's, you know, but tell me what it's like for you when you, when you think about sex. Like, you know, tell, tell me, you know, what does it feel like? You know, what stands in the way? You know, and make that inquiry a genuine inquiry. Just tell me about your experience. Don't immediately go into problem solving mode. Like, you know, listen and show empathy. And I mean, you know, they may then go, you know, would you be, you know, would you be open to us having a problem solving conversation about this? You know, would it feel, you know, fair, reasonable for us to try and talk? Is there a way we could increase the frequency of six. That's, you know, that's not a horrible thing to say to you, but I think.

[Melody Thomas]

Could you.

Sorry. Would you also potentially add in, you know. Yes. Would it be okay to have a problem solving conversation about increasing frequency of sex and. Or, you know, making sure that the sex that we're having is really enjoyable for you? I am like open to changing it up if there's other things that you'd prefer around this time, like just making that. Always opening up that space.

[Nick Bates]

Yes. Yeah, absolutely. Absolutely. I guess for me it's a sort of an absolute bedrock assumption. It's kind of like, how do we make this pleasurable for both of us?

[Melody Thomas]

I like what you said earlier, Nick. You just kind of said it in passing, but you said for those of us who are lucky enough to get old. And I. I feel like the catastrophizing doesn't just happen around menopause and loss of erection. It just happens around aging. Right. You know, it's not often framed as. As something to look forward to, but you're so right. It's a privilege to get there.

[Nick Bates]

Absolutely.

[Melody Thomas]

I feel like that's a very valuable reframe just generally on life. But that will really help you in this area as well.

[Nick Bates]

Yeah, look, I think so. And also the knowledge that, you know, if we're talking about sex, it's kind of like sex can get, you know, can go on changing for the better. You know, like, there are challenges, but if you overcome those challenges, it can be better. I mean, there is an historical. For women around the freedom that comes with menopause, the freedom from worrying about contraception and the risk of pregnancy, you know, can be a really nice thing. So there, there are changes that come with aging and there can also just be, you know, a sense of perspective, which is quite welcome in realizing that. I don't know if sex isn't going quite the way you want, that it's not the end of the world and. And having maybe a long history of problem solving around that and getting creative and, you know, it's like you can become a lot more relaxed and friendly and fun.

[Melody Thomas]

Beautiful. I hope that that is my future. There'll definitely be conversations going on, for sure. There'll be communication.

[Nick Bates]

I think you're well on track, Melody.

[Melody Thomas]

I'm on track.

Hey, I'm on track. Is there anything you wanted to say that you.

[Nick Bates]

I mean, I haven't said the kind of piece about. A lot of heterosexual couples have quite a set pattern for how they get into Sex that. That, you know, that. That, you know, people initiate in a certain way. And there's a. There's a bit of kissing and there's a bit of fondling and maybe there's a bit of oral sex and then they have penetrative, you know, intercourse. And. And it's kind of like. It's quite a set, set process. And, you know, that. That kind of narrative, that arc of how sex happens is very set. And, you know, it's maybe one that's worked very well for them historically. It's been very functional. And because both know the script, it feels very safe. It doesn't provoke anxiety about trying to work out what we're going to do because we both know what's going to happen. But it can get very boring. So it has its inherent problems. And of course, if there are changes in your body, then it can also, you know, it can no longer work that way. One of the things that can happen, particularly kind of into menopause, where the changes that are happening for the woman and the changes that are happening for the men can really set them up in opposition in terms of their approach to the speed with which sex happens. Because what happens for some men is as they become anxious about their erectile functioning, they wanting to get to penetrative intercourse really quickly because they don't trust that their erection is going to be sustained. And they're not talking about that very often. They just have that anxiety and they're kind of, you know, they're pushing towards, let's get the penis inside the vagina real quick. And their partner's feeling that pressure. And of course, they're often going in the opposite direction where their arousal is slower. They're wanting to slow things down. And there's this shit, huge tension between their respective anxieties. And if nobody's talking about actually what's going on. And I have to say, in my experience particularly, the men are often very poor at actually owning how much anxiety they're feeling about their erectile functioning. You can have this real conflict and the men can look very uncaring of their partners and the woman keeps saying, hey, I keep telling him to slow down and he's not slowing down. It's kind of like he doesn't care about. But actually he's full of anxiety that he's not talking about and he's embarrassed about him. It's a really sad scenario, and it's one of those ones that, you know, it can be solved if people are actually willing to take the risk. Of the intimate conversation about this is what's going on for me. And of course the men have to move away from penis and vagina being the be all and end all of sex.

[Melody Thomas]

Thank you so much Nick. That's clinical psychologist, sex and relationship psychological therapist and author Nick Bates on managing the changes that come with aging within our relationships. Before that we heard from Dr. Olivia Smart about menopause and how to manage

some of its symptoms.

I hope this episode is helpful to you whether you're in this or whether it acts as a heads up as you head into the stage of life. And if you do know others who are going through these changes or who are supporting people who are, then do send it on to them. I'll see you soon for the next episode of the Good Sex Project. Thank you so much for listening to the Good Sex Project, made with the support of New Zealand on Air and released through Stuff Co nz. If you think this information is as important and timely and necessary as we do, then please share it with your friends. Tell strangers about it. Send it on the download of that one person. You really needs to hear this info. Help us get it out to as many people as possible. If you want to get in touch with me or the team, please send us a message on Instagram. We're at Good Sex Project or you can email goodsexprojectmail.com we love to hear from you, especially when you have your own story to share. The Good Sex Project was made by PopSoc Media. It was written and developed by me, Melody Thomas, our producer and audience. Our video editor is Kirsten Johnstone and our co producer is Alayna Bates.

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Acast powers the world's best podcasts. Here's a show that we recommend.

[James Richardson]

Hello there. I'm James Richardson and I host the Toady Football Show. Now, this summer, the biggest sporting event in the world, the Football Men's World cup, is heading to Canada, Mexico, and especially the United States. We're going to be there too. We are packing up and heading to Los Angeles for the duration. Which means that every day straight after the last match has concluded, you can catch some hot takes, instant reaction, and insightful analysis from ourselves sat around the pool in la. Sounds like we're going to have a lot of fun doing it. I hope you're going to be joining us too. It's from June 10th all the way up to July 19th, the day of the final. Just search for the Totally Football show wherever you get your podcast.

[Acast Announcer]

ACAST helps creators launch, grow and monetize their podcasts everywhere. Acast.com.