One morning when I was winding up my morning ward round as an intern, a nurse called for help to resuscitate a patient.
It was a 67-year-old woman who had been admitted the night before with what appeared to be a mild heart attack.
Just an hour before, I had been at her bedside, where we discussed her condition and planned her subsequent care.
Accompanying us were counsellors who offered new patients HIV counselling, and if they consented, tested them for HIV and told them their status.
The 67-year-old had been stable and pleasantly cheerful despite her discomfort, and we moved on to the next cubicle just as the counsellor was getting to her bedside.
Now, surprisingly, we were being called to resuscitate a woman who had chatted with us while seemingly stable just an hour before. It was unsettling to lose the battle to a heart attack.
As we drew the sheet over her face and the nurses wheeled her body away, the counsellor drew me aside and told me that that patient’s HIV screening test had turned positive but she had died before the news was broken to her.
The news of her status drew mixed reactions from the medical team. This was back in 2007 when HIV was still running riot but more and more patients were accessing the life-saving anti-retroviral drugs.
However, majority of the population on treatment were still just a few years old in the era of comprehensive care.
Our patient had displayed no symptoms of the infection hence this was an incidental finding during routine care. She had been widowed for 16 years and had no probable sexual partners known to her family.
We debated briefly about disclosure of her status to her children but rapidly agreed that since the diagnosis had not contributed directly to her death, and the patient herself had died without being aware of her status, we had no right to disclose the information.
However, an unspoken question hung in the air for some in the team; how could a post-menopausal widowed lady possibly be sexually active?
Majority of HIV infections in Kenya among adults are known to result from sexual transmission among heterosexual partners, hence the assumption on how she could have acquired the infection.
A few years later, a friend brought her mother to our clinic for an annual wellness check-up.
The mother had steadfastly refused to have a Pap smear done and my friend was exasperated. As she stepped out of the room, she wished me luck.
The patient was 57 years old and though initially shy, we struck a rapport and she opened up. I was impressed when she raised the issue without prompting, asking if it was normal to have sexual desire at her age, especially since she had been widowed for five years.
It was a refreshing conversation and ultimately she did agree to have her first Pap smear done!
These two incidents left me thinking about the assumptions made about sexuality in menopausal women. Very few doctors ask their patients about their sexuality yet it is an integral aspect of health.
GRADUALLY LOSE INTEREST
It is assumed that these women gradually lose interest in sex and this loss seems to have been accepted as the norm, rather than be viewed for what it is, female sexual dysfunction.
It is estimated that among all women, the prevalence of sexual dysfunction is 25 per cent to 63 per cent. This rises to 68 per cent to 86 per cent in the post-menopausal group. Coupled with the fact that most doctors do not ask about it and most women will hardly raise the issue during a medical consultation, let alone seek for help, the condition becomes accepted as normal.
It is therefore not surprising that women like my patient, who fall in the 14 per cent to 32 per cent bracket of normal function are regarded as the “abnormal” ones.
Menopause causes changes in hormonal levels, significantly lowering oestrogen and testosterone, a state which precipitates sexual dysfunction.
All women have small amounts of testosterone in their system that serve to boost libido. After menopause, as these levels decline, it may result in waning sexual desire, sexual response, and orgasm.
Low oestrogen levels may result in vaginal dryness and vaginal wall thinning, hence easier bruising and decreased sensation, all resulting in painful intercourse.
It is important to note that before sexual dysfunction is pinned on menopause, the doctor needs to ensure that it is not a result of medical conditions such as diabetes, heart disease, urinary tract infections and even depression. It may also result from the use of certain medications and negative body image.
It is therefore imperative that we flip the card and assign the correct narrative. Normal post-menopausal women have a right to enjoy complete sexual health, to desire sex and to enjoy it. It is not a disorder and neither is it a moral issue.
For women struggling with sexual dysfunction, there is plenty that can be done to manage the condition and attain an acceptable standard of sexual health. Their basket is already full with arthritis, sciatica and other old-age ailments they may not have control over. At least let us eliminate the one problem we can.