E6:" Menopause and Midlife Bliss:Unlocking Pleasure & Sexuality with Dr. Claire Macaulay"

Dr. Claire Macaulay dives into the power of sexual pleasure in midlife, urging us to tune into our bodies and challenge old beliefs. She explores the transformative impact of pleasure on personal growth, stresses the importance of boundaries, and delves into managing menopause symptoms like vaginal dryness. With insights on lubricants, libido, and HRT, she offers a holistic view on midlife sexual health. Don't miss her take on the Midlife Sex Festival, a valuable free resource for support and information. Tune in now!

Takeaways

• Vaginal estrogen creams or tablets can be used to alleviate symptoms of vaginal dryness and pain.
• Moisturizers, both prescription and over-the-counter, can help hold moisture in the vaginal tissues and provide soothing relief.
• Creating a loving and caring relationship with our genitals is important for overall sexual health and well-being.
• Using lubricants can enhance sexual pleasure 
• Libido in midlife and menopause is often responsive rather than spontaneous, and it is important to create the right conditions for desire to arise.
• Taking responsibility for our own sexual satisfaction 
• The Midlife Sex Festival is a valuable resource that offers free access to talks and discussions on midlife sexual health.
• The link between HRT and breast cancer 

Freebie for listeners -
Midlife Sex Festival https://www.midlifesexfestival.com/
Claire's Website https://www.pleasurepossibility.com/?r_done=1

Laura is a life and menopause Coach and a wedding Celebrant. Find out more below.

Free Menopause Symptoms Tracker https://static1.squarespace.com/static/5e61009edab1950197f83896/t/62a0798f79934a0dfbdca666/1654684094105/Free+menopause+symptoms+tracker+

Email: laura@marvellousmidlife.co.uk

Website: www.marvellousmidlife.co.uk

Linked In: https://www.linkedin.com/in/laurashuckburgh/

Instagram: https://www.instagram.com/marvellous_midlife/

Website : https:www.thechateaucelebrant.com/

Facebook: https://www.facebook.com/marvellousmidlife/

Transcript

Laura (00:01.262)
Hello everybody and welcome to the Marvelous Midlife Podcast where I talk to inspirational midlifers who are doing something amazing with their lives, helping women, supporting other women, maybe forging a path that others aren't on and generally just having a great time chatting to these women. So today I've got another amazing woman on, I've got Dr. Claire Macaulay on today and I'm thrilled to be talking to her. We're going to be talking about

sex quite a lot today. So Dr. Claire Macaulay is a medical doctor. She treats people with breast cancer and she's also a somatic sex educator. She's passionate about supporting people to create a sex life that's right for them. Her brand of science backed, no bullshit, real world education for midlife women creates vibrant and safe spaces. So welcome Claire, it's lovely to have you here.

Dr Claire Macaulay (00:57.089)
I'm delighted to be here Laura talking about my favourite topic. Thank you for having me.

Laura (01:02.014)
Oh, it's an absolute pleasure. And hopefully we're gonna be talking more about pleasure as we go into it, because one of the reasons that I wanted to get you on is that I think from my own experience, my own work that I do with menopause or women, it becomes quite clear that we can sort of lose ourselves within the whole menopause transition. And often there's a loss of confidence and that...

can just, that sort of impacts everything that we do. And I think that we start to think that we are not worthy of having stuff that is pleasurable and going after what we need. We've been so busy looking after everybody else. So I'm really interested in how we can bring more pleasure. And in this conversation, it'd be great to talk about sex because I just think it's so important as we go through the menopause transition that we start to look at what we want.

what we need and what is going to support us and bring us pleasure for the next sort of like 30 or 40 years that we might be living, maybe even longer. So you work with people who have cancer and you're also a somatic coach, sex coach. So what does that actually mean then in terms of people who may not know what somatic means even?

Dr Claire Macaulay (02:09.549)
Yeah, so the way in which I work in terms of my kind of coaching experience and working with people around their sexuality is to actually work with the body. You know, often when people talk about sex therapy or they go and see a sex therapist, people sit in a chair and they talk about stuff and they get away and get homework to do on their own. And that's fine and that's really important. There's lots of aspects of the psychological aspects of sexology and pleasure and what that means to us that we need to address. But we also really need to get in and about the nitty gritty of the body. You know, our body, our

there's a book called The Body Holds the Score. So the body keeps the score of all of the things that have happened to us. And our body has its own voice and its own wisdom and its own way of telling us things, which we're very often not paying any attention to whatsoever. And when we're not paying attention to the signals that are coming from our body, it can actually be quite difficult for us to experience pleasure. Because we need to be able to tune into signals, our experience, amplify them, make them bigger, enjoy them.

bring them online. And if we're not actually able to listen to our body at all, it can be extremely difficult to experience pleasure of many sorts, not just sexual pleasure, but all sorts of pleasure, because we need to be able to move our focus of attention to amplifying the experience that we're having. And that's why I work with the body. I do a lot of mind-based things as well, but it's about working with the body and mind together to amplify our experience of pleasure, which as you say is so important. And often my experience is that

People at this point in their life don't know what they want. They've spent a whole life subjugating their own needs, putting other people first, dealing with kids, elderly parents, whatever it is, and they don't actually even know what it is that they want. And often that's where I very start at the very beginning. What is it that you want for yourself? And if you don't know, that's fine, but let's figure out what it is because you can't have what you can't want.

Laura (03:56.906)
Yes, I've been doing quite a lot of work around like just lately and the word that's coming up and it just happens to be that you know it sort of links into our conversation is desire, you know, what do we desire and sometimes I think that we feel guilty for vocalizing what we desire or what we want. It sometimes maybe feels like it's a selfish thing but actually you're so right we have to listen in to what our body needs so that we can

Dr Claire Macaulay (04:06.53)
Yeah.

Dr Claire Macaulay (04:13.905)
Mm-hmm.

Laura (04:24.902)
we can hear because when I'm working with women, I often get them to start meditating because they're often so in their heads that actually there's all this buzzing around and noise that's going on and within that you know some negative sort of voices inside and maybe a lack of self compassion for sure often is the case and if we can get into our bodies and out of our minds which is that what somatic actually means then?

Dr Claire Macaulay (04:34.219)
Yeah.

Dr Claire Macaulay (04:52.466)
Yeah.

It means working with the body alongside the mind and not discounting it, you're recognising that it has its own wisdom. You know, just to pick up on one of the things you say, I'm also a relationship therapist, I work with couples and one of the lines I use a lot with them is, you cannot be resentful for not getting something you haven't asked for, which really feeds into this desire piece. If you haven't vocalised that you want something, why are you resentful with your partner that you're not getting it? And that feeds into this piece.

that I think we are socialized often as women not to express what our wants are, not to put our needs in the space, taking care of everyone else's needs and desire can be quite a potent word for people you know there's lots of connotations about what that means along you said selfishness, desires that I shouldn't want you know so this idea that there are things that are okay desires and things that are not okay desires and actually a lot of the work that I do with people is unpicking all of that why is it

that you believe what you believe at this point in your life. I say to people all the time, your 12 year old self is running your sex life whether you know it or not. Because if you haven't gone back to look at the messages that you've internalized, the early experiences that you've had, those things are running your life now. And this is a perfect opportunity.

to go back and go, okay, what do I believe? My goodness, I didn't even know I believed that, and that's probably running my life. Is that a belief I want to hold on to? Do I want to let go of it? And if I let go of it, what is the room for? What do I actually want at this point in my life? Now, and all of that work is so liberating, I think, for people.

Laura (06:28.798)
Oh my goodness, definitely. Because it's making me think of the stories that I was told as a child that became my kind of narrative around sexuality. And then also a lot of women, so many women, I remember sitting in a room years ago when I was modelling, there was a room, there was seven of us, we were all on a trip in America, traveling all across America, it was fantastic. But in a room of seven, there was five women in that room who had some sort of sexual abuse or something had gone on. And so we have to often,

Dr Claire Macaulay (06:38.106)
Yeah.

Laura (06:59.418)
for me, from my point of view, because that did happen to me as well when I was younger, that I found that sex was about giving and not receiving. You know, it was about pleasing somebody else. And I think that, so that's caused a lot of issues for me, you know, and that I've had to kind of, you know, look at and unpack really. And I think as so many women have had something negative happen sexually.

Dr Claire Macaulay (07:07.873)
Mm hmm. Yeah.

Dr Claire Macaulay (07:26.701)
Yeah, absolutely. And I think, you know, if we talk about the kind of heterosexual dynamic to start with, you know, that theory of sex is for men, that internalised belief that pleasure is for men, it's about men, it's about them, it's about me doing something to pleasure a man or making myself available in some way for someone else's pleasure is really, really pervasive. And a lot of the work that I do with women is about helping them to reclaim that pleasure is for them.

it is equally as important that they have a pleasure experience. We have this amazing, phenomenal body that is capable of untold amounts of pleasure. But if we think that pleasure is all about somebody else, then we're not going to tap into what it is that is available to us and why it's so important. It's so important for our mental health, for our physical health, for our emotional and spiritual health. You know, it's such an important part of being a

Laura (07:54.463)
Mm.

Dr Claire Macaulay (08:19.065)
alive if nothing else. We're animals ultimately and it's part of our animal nature and if we're not living in a place where our sexuality is online then we're not actually living a completely whole human existence.

Laura (08:20.651)
Yes. Yeah.

Laura (08:32.086)
Yeah, that's so true. And when you're talking there, it was also bringing up for me about, you know, like as women having that kind of pleasure aspect, but also that feels like, from an experience of my own, as well as what I've heard from other people, is this whole kind of confidence thing, you know, body confidence, and how that plays into how we feel sexually as women. And being able to just be fully kind of okay with how-

we are and we are perfect as we are rather than being very conscious of maybe how we look like when we're with people and when we're having sex or because it's we see so much online all the time about how a woman is meant to look a certain way and then you know body you know all of this sort of like revering youth in our western society which has a massive impact i remember feeling very conscious of the way i looked when i had early sexual encounters and um

And then how would I then be confident to sort of allow myself to think, well, is this about me? I was just too conscious.

Dr Claire Macaulay (09:35.513)
Yeah, and we know from research that the things that impact people's sexual experience and the way they feel about their sexuality hangs a lot around how they feel about their body. And also the experience that they're having in a relationship, let's say they're having sex in a long term partner relationship and the quality of that relationship. So there are two things that are really very, very important. And what I say to people is, you know, this amazing body you have is capable of all of the same sensations and experience, regardless of its size, regardless of the texture of your skin, regardless, you know,

physicality of our body. Things change with age and we can maybe talk about that but the physicality of your body is capable of pleasure irrespective of what it looks like and when we start to get into that your body is a vessel through which you can experience things no matter what it looks like that can start to change the game for people. If what you want is to have more pleasure in your life you already have all the apparatus that you need.

Laura (10:30.338)
So it's just actually believing that you can have pleasure. That's a lot of it, isn't it? The belief that you are worthy of pleasure if you want to have pleasure.

Dr Claire Macaulay (10:33.809)
Yeah.

Dr Claire Macaulay (10:38.153)
Yeah, and that's why what I run is called the pleasure possibility. You need to be alive to the possibility that is available to you, first of all. And that's where a lot of the early stuff, the beliefs, the messages, what you believed, your early experiences. We need to unpack some of that so that we can start to understand what it is, why you believe what you believe, so that we can move you to something different if that's what you want. If you want something different from what you have now, then we need to do something differently, ultimately.

Laura (11:05.215)
It must be a wonderful thing to watch people who come to you, who start to find their kind of, you know, their sort of sexual pleasure again and to sort of shine again through it and to feel good within it.

Dr Claire Macaulay (11:08.541)
Sheesh.

Dr Claire Macaulay (11:15.533)
Yeah, it is the very best job in the whole world, I have to say. And I think the reason that it's so fulfilling and the thing that really matters, I think, is, yes, people have better sex. They might have a better relationship with their body. They might feel lighter. They might feel freer. They might feel more expressive in the world. They may have a better pleasure-filled experience. But what actually matters to me is what they then do with that. So they might leave.

crappy marriages, they might get a promotion at work, they might decide to start their own business, they might decide to go on a world trip, you know, around the world trip that they've always wanted to do. The sex is just a vehicle to confidence, to feeling vibrant, to feeling worthy, to...

actually getting on and doing whatever it is that your purpose is in the world that may, you know, the second half of life, particularly maybe if we've had children, you know, the second half of life is what is the point now, what is the purpose of this. When your sexuality is online and you're available to be fully expressive, whatever, you know, it starts to support whatever it is that you want to be for the second half of your life.

Laura (12:22.422)
Yeah, and it's lovely listening to that because it really, it echoes. I'm not a sex therapist and I'm not a doctor, but the work that I do with women.

also helps them to feel empowered and sort of like more vibrant in themselves to be able to do what they want to do and so that takes me on to sort of there's been a lot of talk about talking therapists in around menopause and I do believe that any kind of talking space whether it's with a sex therapist or a cb or coach or whatever is a really wonderful place for a woman in midlife to

to try if you've never had any kind of talking therapy. And sometimes, you know, the beginning you said, what do you want? Sometimes women have never been asked that. What do you actually want or what do you need? And it's such a valuable container really, that sort of that talking space container.

Dr Claire Macaulay (13:01.434)
Yeah.

Dr Claire Macaulay (13:06.937)
Yeah.

Dr Claire Macaulay (13:15.277)
Yeah, I think so. I think it depends what angle you're coming at it from, but I don't think it actually matters what that container is. It might be a therapeutic container, maybe there's something very specific that you need psychotherapy for. That could be early childhood trauma, it could be things that happen to you, it could be an infertility journey, it could be all sorts of different things that may have happened that you want to deal with. And I love a coaching capacity because a coaching capacity goes, OK, and all of those things are true and have happened. And where do you want to go?

What do you want to do? What's the next stage? What's, you know, where do you want to take all of that? So I think it's so important for people to have space. That's why I do what I do actually is because nobody was talking about this and I knew it was a massive issue. So making the spaces for people to come say, OK, me too. Yes, that is my experience, because once we can start to acknowledge and validate our own experience, then we can decide what we want to do with it. And sometimes we might need help and support.

to get where we want to go and that's perfectly okay. We are entitled and deserve to have the help and support that we need to move us forward to wherever it is that we want to go.

Laura (14:16.294)
Often we're not very good at asking for that though. Ha ha ha!

Dr Claire Macaulay (14:18.317)
Yeah, absolutely. And a lot of what I do, once we've figured out what you believe and what you don't believe and what you want, then the next stage is learning how to ask.

and noticing, I do some somatic exercises with people around noticing what yes feels like in their body and what no feels like in their body. And once we've got a felt sense of what it means to say yes to something when you really mean no and what it means to be saying no to things that might be pleasurable when actually somewhere if you were confident enough you would say yes, once we can tune women into what does yes feel like in my body and what does no feel like in my body.

then they can start to answer and show up more authentically in their lives with a genuine yes and a genuine no, I can't do that for you right now or yes, perhaps I may be able to do that, but I need this first and starting to learn to articulate and ask for things because you cannot be resentful for not getting things you didn't ask for. And so we have to be able to teach people how to ask and often we've not been taught how to ask for what we want or advocate for our own needs. And so yeah, absolutely learning how to ask for things. This is the

Laura (15:08.526)
I'm gonna go to bed.

Dr Claire Macaulay (15:20.209)
helpful point in life to be able to learn that if you haven't done so far.

Laura (15:24.126)
Yeah, we need to be teaching this sort of stuff in schools really, Claire. You know, especially that, I really love that learning how it feels in your body to say yes or to feel yes and to feel no. That's really important and, you know, maybe that would help so many younger people to get out of situations or to just be able to get into situations, if they were honest.

Dr Claire Macaulay (15:28.21)
Yeah.

Dr Claire Macaulay (15:40.903)
Yeah.

Dr Claire Macaulay (15:44.761)
Yeah, I think if you feel, yeah, and you know, one of the things that I often say to people is if you can't say no, then your yes means nothing.

And we're conditioned, often those of us who are socialised female, we're conditioned to say yes to other people, to say yes to what they want, to say yes to other people saying, yes, I'll do that for you. Of course, no problem. I'll do that when actually inside we're going no. But at some point we've overwritten those internal signals that tell us that our no is a no and we're doing it anyway. And that is a breeding ground for resentment. It also means that if you can't say no to somebody, then your yes might mean yes.

But it also might mean maybe, and it also might mean no. So we need, and often we have been socialised not to say no to people. So finding people's authentic no and supporting them to be able to use it. No, actually I can't come and.

look after your kids this weekend or whatever it is, but I am willing to do this feeling confident and comfortable to know that you're a no rather than doing things and feeling resentful, being burnt out, not having enough time for yourself, all of the things that we know that come as a consequence of not being able to say no. So in order for our yes to be an authentic full on fuck yes, then we need to be able to say no when we actually mean no.

Laura (16:56.814)
We do, we do. And also we need to perhaps have like a bank of responses. I quite often get people to think of when they're gonna, you know, when we talk, when I'm talking about boundaries and strengthening boundaries is sometimes to think, well, maybe write out some nice things to say that you feel comfortable saying that mean no, like, no, I can't this time, but maybe next time, or I don't want to come because I am doing something else.

Dr Claire Macaulay (17:04.517)
Yeah.

Laura (17:25.486)
whatever it is, you know, whatever it is to you, but often that can be helpful, I find, because then you don't have to think about the response so much.

Dr Claire Macaulay (17:31.241)
Yeah, yeah. Yeah. And often I think people when I talk with people, I do a lot of people around consent and boundaries, and people don't like the idea of a boundary. They don't like even the concept of the fact that they might, you know, it feels like a like a like a fortress or something

Dr Claire Macaulay (17:52.669)
from the world, they protect us from the outside things that might be difficult for us, but they also, there's also an internal boundary that protects the world from us, protects the world from the worst of us on the inside, so boundaries are a really important way of regulating our...

Laura (17:54.079)
Yeah.

Dr Claire Macaulay (18:06.393)
nervous system, they're an important way of being able to protect ourselves from things that may be hurtful and difficult for us, but they're also a way of protecting other people from the worst of us. If we say yes to things and we're resentful and we let that resentment out in some other way, in some other place, at some other time that affects someone else that it's not got anything to do with, then we have allowed our boundaries to be transgressed on the way in by doing something we didn't want to do, but we've also not protected someone else from the internal boundary of our resentment. So boundaries are really important in terms of being able to...

contain ourselves and keep the core of us authentic and safe.

Laura (18:41.322)
Wow, I love that. That's really fascinating. I've never thought of that before, the kind of boundary on the way out. I know about resentment and what, you know, if you don't say what you need, how that, you know, resentment can build up. I've learned about that in some CBT stuff I've been doing, but I hadn't thought about that, you know, being bounded both ways.

Dr Claire Macaulay (18:58.937)
Yeah, protecting other people from the worst of us, which is fine, we're all entitled to have the worst of us, but we also have to make a choice about how we're going to show up with that in the world. How are we going to manage the things inside of us that, you know, none of us are, all of us have got unprettiness and things that are difficult on the inside and ways of being that we don't like and all of those kind of things. And actually, how do we protect the people round about us from the worst of us?

Laura (19:21.506)
Yes, it's a fascinating point. Okay, so, so many places I want to go in this conversation, but I'm thinking let's go to menopause if we can, and some of what happens to us in the menopause phase that impacts on our sexuality and our sex lives. So can we talk a little bit about that?

Dr Claire Macaulay (19:46.097)
Yeah, of course, this is my favourite topic because nobody told you when you were getting your sex ed at school that your fanny might shrivel up and die, did they? Nobody told you that! And it's so important because let's just talk about, you know, well, I mean, obviously you've talked lots about the menopause on the podcast previously, but obviously the menopause is when our estrogen levels are dwindling over time, that perimenopausal phase when things might be all over the place feels a wee bit more like a kind of second puberty, but at some point those estrogen levels will decline and they will fall off to what we call postmenopausal.

levels will no longer be ovulating, we will be having regular periods etc so that's the menopause as it is and that fall in oestrogen so we have oestrogen receptors on all cells in our bodies but the tissues in our body that are most sensitive to oestrogen are those in our pants so that's our vulva vagina, clitoris, pelvic floor, bladder and our urethra where we pee out of, they're exquisitely sensitive to oestrogen and when that oestrogen starts to fall at menopause

those tissues that require estrogen to be functional and well have less estrogen and they start to die off, literally. It's called vaginal atrophy, the word atrophy is a hideous word but it means withering or dying. And it means that those tissues that were working to support our arousal, to support our urinary systems, to support our pelvic floor health, no longer have the estrogen that they require to work properly.

And that means that we know somewhere between 60 to 70% of women are going to have problems in their pants. That might be vaginal dryness, it might be pain, it might be loss of sensation, it might be decreased orgasm, it might be urinary tract infections, or it might be prolapse, or it might be incontinence. So all of those issues can occur together and separately, and they are all together encompassed under the term that we call the genitourinary syndrome of the menopause.

and it is something which we don't talk about. We're starting to talk about it now, even as this explosion about the menopause has come forward and we're talking more about the menopause, actually talking about the practicalities of what's happening in your pants and the fact that it's real and you're not making it up and yes, your clitoris might be shrinking and yes, you might, your orgasm might not be as strong as it was before, all of those things are real and many women don't know that.

Laura (22:01.182)
Yeah, thank you for that. And often, they can be one of the first signs or impacts of like going into perimenopause. And if you're going into perimenopause between the ages of 40 and 50, which most women do, you

you might not even put two and two together, you might not think well, because I remember being very itchy down in my pants. And, but at the time I hadn't even heard of the word perimenopause. And I was thinking, what is this like intense itching all the time? And now I realized that it was, it was that was one of my symptoms. Another friend of mine had recurring UTIs, urinary tract infections, always had a UTI and didn't realize. And as soon as she got some estrogen, she felt much better. So,

Dr Claire Macaulay (22:22.799)
Mm-hmm.

Dr Claire Macaulay (22:32.378)
Yeah.

Laura (22:43.966)
We do need to talk about it more so that people recognise what's happening to them, recognise the impact, because it's not, venipause is not just all hot flushes, is it? It's much more, there's many more symptoms than that. So within GSM or genitote.

Dr Claire Macaulay (22:51.717)
No.

Laura (22:58.754)
What is it? Genital urinary syndrome. Yes, so there's various different things in there. So there's genital symptoms, which can be the dryness, the itching and the irritation. There can be sexual symptoms, which you like the loss of lubrication, discomfort, and then the urinary symptoms, frequency of going to the loo, getting up in the night, which I've got, nocturia. I've done my research into that, which is so annoying, and especially impacts on our sleep, which is another massive menopause symptom. So what can we be doing then, Claire,

Dr Claire Macaulay (22:59.505)
Genital urinary syndrome of menopause.

Dr Claire Macaulay (23:15.961)
Yeah, getting up at night. Mm-hmm.

Dr Claire Macaulay (23:23.857)
Yeah.

Dr Claire Macaulay (23:27.981)
Okay, so there are lots of things to be doing. The way that I think particularly around the genital urinary system, there's kind of three main branches of things that we can be doing. We'll start with hormones first of all. So there are hormonal treatments that can help with this significantly. Now you might choose to be somebody who uses full HRT, by which I mean that might be patches or gels or tablets that you're taking HRT to manage all of your symptoms may also manage your genital urinary symptoms as well.

Laura (23:29.011)
this.

Dr Claire Macaulay (23:57.145)
What we do know is that about a quarter of women who are using full HRT may still have additional vaginal symptoms and vulval symptoms that are not managed by HRT even though they might be using patches and gels and all the rest of it. So even if you are on HRT about one in four of us might need additional support locally in the vagina.

Equally, if you're somebody who chooses not to use full HRT, it's not for you. You don't want to have it. Your symptoms aren't bad enough. You're not worried about it. You're using other methods, alternative methods, complementary methods to match your symptoms. You can still use hormones locally in the vagina if the gen 2 urinary syndrome of menopause is problematic. And what that is, is it's either little tablets or gels or sometimes a pessary or a little and a little kind of bullet pessary that you can use locally in the vagina that gives.

literally estrogen just locally to those tissues. So you insert them, usually we treat everybody for two weeks initially, a two-week course of treatment initially, and then you would use it maybe twice or three times a week. It can be creams, it can be pessaries, it can be both. For most people I suggest that if they're having difficulty is that you use a pessary, some people have heard it be called Vagifem or there's another one called Vagirucks that's got less plastic waste, which is a tiny tablet that you put in the vagina twice a week after you've had a two-week loading.

and also to use some cream externally. So it might be an estrogen cream or vesting cream, something like that, that you can use externally, that you can use on the labia and on the clitoris to help support estrogen locally. Now, for most people, it's extremely low dose to the rest of your body. So we know that from studies that using vaginal estrogen for a full year,

gives the same absorption into the rest of your body as one HRT tablet. So the amounts of estrogen that are absorbed within into your body are extremely low. So even people who are choosing not to use hormones or can't use hormones, for example, most people can use vaginal estrogens, whether they choose or not choose to have full HRT and it is extraordinarily effective. It's extraordinarily effective because all we're doing is replacing that estrogen that those tissues need.

Dr Claire Macaulay (26:11.289)
to be healthy. And what I say to people is, you know, for many of our symptoms of menopause, the hot flushes and the insomnia and all that kind of stuff may get better as we get older. So we might go through this menopausal transition and a lot of that will settle as we get older and we'll have an old age free of problems like hot flushes and all the other things. However, because the genital urinary syndrome of menopause is

reducing the actual treatment, reducing the actual tissues that are there, those symptoms are not going to get better with age. If you have symptoms of vaginal atrophy or UTIs, that is not going to get better as we get older. So I suggest to people, no, no.

Laura (26:46.018)
So the dry vagina is not getting any more lubricated unless we help it along as we get older.

Dr Claire Macaulay (26:50.765)
Yes, absolutely. And you know, so you can have a functioning fanny for as long as you want using vaginal estrogens and that you should consider that to be a lifelong treatment. It's not something you're going because you'll treat it, it'll get better, you'll stop it again, it'll come back. So you know, if your GP says I'll give you a 12-week course, well that's fine, but actually that treatment needs to be continued lifelong or for as long as you want to have a functioning fanny, which is the way I used to describe it. So that's the first lot of treatment.

Laura (27:00.979)
Okay.

Laura (27:16.27)
What's the... I was just going to ask you because I use the applicator one with a lot of plastic in it, which I find concerning. So what was the name of the other one that you said that hasn't got as much?

Dr Claire Macaulay (27:22.417)
Yeah.

Dr Claire Macaulay (27:28.505)
So there are other ones you can get generic estrogen because it's not, it's something that you can get in generic form. So Vagifem is just a brand and you can get generic forms of Vagifem that come with a blue applicator. Those who have seen it will know what looks like a little blue applicator with a tiny, tiny tablet at the top of it. And you can get other ones that come with two reusable applicators in the packet and a packet of.

Laura (27:36.788)
Yeah.

Dr Claire Macaulay (27:49.329)
you know, 20 or 36 or 48 tablets, for example. So you can ask for that at your pharmacy. You can say you would like, if it's not prescribed by a brand name, and it probably would be, then you can ask to have the ones with less plastic.

Laura (27:50.75)
Oh, that sounds better.

Laura (28:01.582)
Okay, perfect, that's great advice, thank you.

Dr Claire Macaulay (28:04.205)
So that's the kind of first way of looking about how we manage.

the vaginal dryness and pain and soreness particularly. The next piece is around moisturising. So obviously you're not where our vagina is not creating the same moisture as it once did. The pH, that's the acidity level in our vagina changes as that dryness becomes more problematic and that changes the type of bugs that are growing within the vagina itself. And so we can use moist long-acting moisturisers. So moisturise your face, moisturise your fanny, that's how it goes.

We can use long acting moisturisers of which again you can get these on prescription or you can buy them over the counter which are pH bands and are specifically for menopausal vaginas. And the idea is that they're long acting moisturisers that help to hold moisture within the tissues of the vaginal vault itself, the actual vagina itself and externally on the vulva. So they can also be helpful and very soothing. You can buy specific moisturisers or you can moisturise with any edible oil.

coconut oil, sweet almond oil, any kind of oil that you like. And often I suggest that at this point in our lives, being in relationship with our genitals can start to become really important. So we know that if I suggest to you, Laura, that you close your eyes and you imagine your left pinky finger, you can probably imagine your left pinky finger. If I ask you to close your eyes and imagine your left labia, you may be less able to do so, because we don't have

necessarily a particular relationship with our genitals that has been involved in looking after them. Usually it might have a lot of it has sometimes been fear-based or there's something wrong with it or we've never looked. There are millions and millions of women who've never actually looked at their vulva. So one of the ways I talk about when I talk about moisturizing is starting to create a relationship with a looking after relationship.

Dr Claire Macaulay (29:55.473)
bringing this part of our body to the forefront of our attention, paying attention and being alongside it. Because if you've never looked at your vulva, how are you going to know whether you've got any of these symptoms or you've got any changes? Because you've got nothing to compete it with.

So there's something really important, I think, about starting to create a relationship with our genitals that feels loving, feels tender, feels caring. And that can be difficult if we've ever experienced trauma, for example, if we're having sex that's painful and unpleasant. That's not, you know, that's not something that sets us up for a loving, tender relationship with some compassion towards our body. And if we've had, you know, sometimes if people have had birth trauma or sexual trauma.

There's lots of reasons why we might feel funny about our genitals. And this is a point in our lives where we can start to think about how might we change that, how might we start to create a relationship with them that feels meaningful and supportive. So moisturisers, moisturisers are the next bit. So hormones, moisturisers and the final piece of the puzzle is about lubricants. So it's about lathering lube on everyone if you're engaging in any kind of genital touch.

Laura (30:51.367)
Yeah, it's very interesting.

Dr Claire Macaulay (31:05.945)
And I find such a lot of resistance to this. There is this kind of societal idea that we should just be wet at the drop of a hat and that our bodies will just do whatever they're meant to do and that's what it means to be a sexually liberated being and it's total nonsense. There's all sorts of reasons why our bodies may not lubricate. We might not like the sex we're having.

We might be anticipating that it's going to be painful. We might be thinking about what we're going to make for our tea. The context in which that sexual activity has been set up might not be something that actually turns us on particularly. You know, so there's all sorts of reasons why we may not lubricate.

in a way that we expect ourselves to, and certainly with the hormonal changes, our body may just not be able to lubricate in the same way. So thinking about a lubricant, having a discussion with a partner, thinking about lubricants when you're using sex toys and making it part and parcel of what you're doing rather than sometimes people feel it's this kind of hidden, kind of dirty secret that they need a loop, for example. But, you know, there's millions of different types of loops out there. Look for a pH balanced one. Look for one with no nasties in it. There are some that are made specifically for

menopausal people usually look for an organic one that you mean to have not got glycerin and various other things in them that can cause problems in the vagina but lube is your friend absolutely lather it on everyone yeah

Laura (32:22.51)
Absolutely, and it is about getting the right one because sometimes lube can become you can put some lube on and then it actually Becomes more drying so it's about finding one that's suitable and natural as you say Okay

Dr Claire Macaulay (32:34.925)
Yeah, and might also be using the thing that we call the double glide technique, which is using an oil based and a water based loop at the same time. So they don't mix. So if you put oil on everybody first and then you put a water based loop on the top, you get this idea of double glides because you've got the loop gliding over each other in addition. So there's a company called Yes, who make organic moisturisers, who make an oil based one and a water based one that are designed to go together. So it's just knowing some tips and tricks of things that can actually help your experience feel more useful.

Laura (33:04.758)
Yeah, yeah, which is fantastic to know that we can make it more pleasurable. And then what about libido, Claire? Because as we age, our libido tends to get lower and with the lowering of hormones, it can become even lower than that. And also when we've been in relationships for many years, perhaps, or you've been married and it's not as exciting as maybe it was, how do we ignite our libido in midlife and menopause?

Dr Claire Macaulay (33:31.905)
Yeah, so libido is one of my favourite things to talk about because it is so deeply misunderstood and we are operating from a place of expecting something that's probably never going to happen. So if we talk about desire and libido, we know from research that there are two main camps of desire and libido. One is called spontaneous desire.

And if we start with that, that does what it says in the tin. You know, it's that idea that this surge that comes up and you have this overwhelming desire to have sex. Now, the difficulty with spontaneous desire is that we know from research that that's not the predominant way that those of us in female bodies experience desire, but it is the predominant way that those of us in male bodies might experience desire. So there's a problem there.

Because if we are expecting our bodies to do that, because that's what we see on the movies, that's what it looks like out there, that's what we're conditioned to believe, then we think we're broken when it doesn't happen. But for the vast majority of people in female bodies, they do not experience spontaneous desire and may never actually have experienced spontaneous desire. We do know that experiencing spontaneous desire is more likely at the initial stages of our relationship, so within the first six to 12 months, we all know what that feeling is like.

But that in fact that spontaneous desire isn't maintained over time and the longer you're in a relationship the less likely you are to experience spontaneous desire if you're also in a female body. So I think we need to be really clear at the get-go that what we are, if I say to people if you're expecting the bolt of desire to the fanny it's probably not coming and it maybe never has come. That's the important part is that we have this expectation and that's not necessarily true.

What we do know from research is that those of us in female bodies are far more likely to experience what we call responsive desire. And what that means is that once we start to experience, you know, the sexy context or something happens, our body starts to warm up. And then we experience the desire for it. So waiting for the desire to come first in order to move us forward to having a fulfilling sexual relationship is never going to work.

Dr Claire Macaulay (35:35.365)
The reason that is so important is because once we know that our desire is responsive, we can create the kinds of circumstances to which we can respond and have that experience. And there's a fantastic book by a woman called Emily Nagoski that's called Come As You Are that explains all of this. And the idea is that if you put your body in the bed, the desire may well show up.

Laura (35:45.514)
Yes, create the conditions.

Dr Claire Macaulay (36:02.737)
Having a fulfilling sex life, particularly if you've been in a relationship for a long time, particularly if you're a midlife, is an active choice. You're actively choosing to engage and create the set of circumstances that feel good for you, in order that you can have what you say is important to you, rather than sitting back and going, I've got my libido, I'm not going to do anything about it. I say to women all the time, your libido may never ever...

experience what it was when you were 20. You may never ever experience that again in this relationship that you've been in for 25 years the way you did when you met in the first six months. That does not mean that you can't have a wild, delicious, fulfilling, pleasurable sex life. The libido piece of it is kind of irrelevant to a certain degree in terms of what you can create, but if you are expecting to wait for that to come, then you're going to be disappointed because it's probably not coming.

Laura (36:49.079)
Yeah.

Laura (36:57.666)
That's really fascinating, isn't it? But it's also quite empowering because it means that you can choose to have a good sex life. And it's like anything, we can choose to be happy. You don't, you know, so it's about, it's within us. We have agency to do something about it. So that is a really empowering thing. So it's about creating the conditions so that you can have the sex life that you want and need. And that is possible.

Dr Claire Macaulay (37:02.406)
Yep.

Dr Claire Macaulay (37:11.129)
Yeah.

Dr Claire Macaulay (37:19.897)
Yeah, absolutely. And that's what I, that's what I, once we figure out what women want and we get passed all of the beliefs and things that might be getting in the way, then we need to think about, okay, well, what are the contexts in which that's going to arise for you? What are the contexts that you can create that are going to bring that forward? And our desire, the circuitry in our brain.

in terms of desire and arousal and sexuality has two parts to the system. There are the brakes that switch it off, so that's the things that stop us taking our clothes off in testicles and having sex with a random stranger. For example, there are bits that inhibit our sexuality and there are bits that accelerate our sexuality. And we cannot move, if you think about it, brakes on a car, we cannot move the car forward if the brakes are stuck on. So the first place we need to start is what are the things that are turning you off?

What things do you not like? What things, so for example, one of the things for me is I find it really difficult to get myself in the right head space if the bedroom's a mess or that kind of thing. So actually, what context do we need to create that are gonna switch your brakes off so that your accelerators can move forward? So identify getting really nitty gritty with people about the things that they like and they don't like. What are their turnoffs? Because if you don't turn off the turnoffs, we can't move forward with the turn ons.

Laura (38:30.858)
No, and we are, as women, we are very in tune with that, aren't we? You know, it doesn't take much for us to be turned off, whereas it's much more animalistic for men or much more spontaneous, where for us we need more, the conditions need to be created in much more sort of sensitive way in many ways, so that we can then feel comfortable.

Dr Claire Macaulay (38:39.045)
Yeah.

Dr Claire Macaulay (38:49.593)
Yeah.

Laura (38:52.518)
in wherever we are. So for instance, I'm thinking when you're talking about that, that for me, I really don't like sex when I go to bed at night, because I'm tired, I'm exhausted, you know, getting into bed is not the time, but you know.

Dr Claire Macaulay (38:52.709)
Yeah.

Laura (39:05.854)
in the afternoon, you know, if I'm not working or it's a lovely day, then that would be a more of a condition for me. And I'm much more receptive and feel more alive and ready then. So it's about honouring that, really, isn't it? Knowing what you want and voicing it.

Dr Claire Macaulay (39:12.281)
Yeah.

Dr Claire Macaulay (39:19.29)
Yeah.

Yeah, and also being really clear if you're in a partnered relationship, that's not your partner's responsibility. It's not your partner's responsibility to know, guess, make up.

Laura (39:28.621)
No?

Dr Claire Macaulay (39:33.853)
or otherwise, you know, that is our responsibility to be clear about the things that we need if we want to have this sexual relationship that we want to have. It's starting to understand that we are responsible for the bits on our side of the street that we can do something about. Now there might be specific requests you want to make of your partner, maybe be a partner to something you don't like, or maybe they don't take long enough to...

to woo you or to have that kind of initial, whatever it is, you can still ask for that, but it's not their job to guess, it is your job to know and to put those things forward in the space and hold your own boundaries and be clear about what you want because we cannot expect someone else to guess for us, particularly if.

you've been having unsatisfying sex for 20 years and you've never said anything. That happens a lot. I see that a lot. I've said I'm never really sharpened all that into this, not really. And bringing that to a partner can be difficult, but actually, if you want it to be difficult, different than you have just now, then you're going to have to do something differently.

Laura (40:27.178)
And do you find, if you've found with people who have been in long relationships like that, that it is possible to transform a relationship? That must be amazing.

Dr Claire Macaulay (40:32.961)
Oh yes, absolutely, absolutely it's possible. Now often of course it might not just be the sex you know because sex is happening in the ecosystem of the rest of our relationship so that was one of the reasons actually why I decided then to train as a relationship therapist to try to be able to bring in...

the parts of things which are also just about our relationship and how that's impacting our sex life. But they kind of move back and forward, you know, as you start to get people's sexual relationship, if you can deal with whatever the, if there are some key relational pieces that need sorted, you probably need to address them and bring the sexuality in later. But equally it works the other way around. People's relationships improve because they work on their sex life, mainly because it requires you to communicate more clearly, it requires you to be honest about what you want.

and those skills then spill out into the rest of your life because once you can do it there, that's not, you know, it's not, you know, be about the bush, being in a sexual relationship with somebody is probably one of the most vulnerable things that we can do as a human being in terms of our body, our emotional experience, all of those kinds of things. So once we can start to really be vulnerable and honest and connect there, then we can start to bring that over into the rest of our relationships because our sexuality is the most vulnerable part of us often.

Laura (41:46.926)
Wow. Yes, gosh, it's so much in there, Claire. It's been lovely to sort of like flesh this out, literally to flesh this out, because it's an important topic. I think it's gonna be so valuable. I hope everybody is gonna really enjoy this conversation. So, I am thinking...

Let's talk about your midlife sex festival, because this goes on very nicely from here, and I'm sure you're very passionate about this as well, and I've looked at it earlier online, looks fabulous. So tell us all about that.

Dr Claire Macaulay (42:09.909)
Ha ha ha!

Dr Claire Macaulay (42:19.253)
So what I decided to do was to bring together over 30 of the best people that I know doing this work and it ranged from people who are academics who are doing research in this area to tantra teachers to kink experts to doctors and talking around testosterone and hormones and all sorts of different

Dr Claire Macaulay (42:49.393)
give their expertise about how we can manage to create the sex lives that we want at Midlife. And it's called the Midlife Sex Festival and it's entirely free. It's available, it will continue to be. We ran it live as a kind of, with a whole community, but it's now freely available for anybody who wants to have it to come on. And you can pick and choose, you can look for different talks and we're gonna continue to add to it the way we asked the community of other things that they would like to see and we'll continue to add to it as we go. But it's just a really...

I knew I wanted to make it, but you know that when you don't know how something, you don't know what's going to go when you send something out in the world, you just have to make it and hope for the best. But the feedback has been absolutely phenomenal. People saying it's changed their lives, got the information that they needed. They feel like they can actually move forward in some way. Yeah, and it's free for anybody who would like to take part of it and will remain so. And it's just an amazing resource. I feel really, really privileged to have had the opportunity to speak to such amazing people and bring this forward in the world. It's been an amazing experience for me.

Laura (43:49.206)
Well, congratulations, because it must have taken a huge amount of organisation and work to set that up, Claire. So thank you for doing that for everybody, because it is, you know, it is like you said, it's a free resource, but it's so valuable and it takes a lot of time and energy. So thank you. It sounds like an amazing thing to have. And I'm going to go on because I've already looked, there's so many talks on there. I can't even really know where to start.

Dr Claire Macaulay (43:57.231)
I'm sorry.

Laura (44:14.818)
But what I do want to touch on before we bring this conversation to a close, because you are a breast cancer doctor as well, can we talk about the links between HRT and breast cancer and just kind of, maybe just like, cut through some of the sort of myths and get to the facts? Because I know many women are put off taking HRT or MHT, menopause hormone therapy.

Because they think they can't, because of the old narrative and that old... Oh gosh, what's the word for it? You talk to us about it. I can't think of it.

Dr Claire Macaulay (44:49.085)
Yeah, so I think we need to be clear that the evidence suggests that there is a link, a small link between HRT use and breast cancer because what you will often see bandied about is there is no evidence that evidence has been discredited etc etc. We do know that there is a small link between using HRT and breast cancer but it is the same level of link and risk as drinking two glasses of wine a day and breast cancer.

Laura (45:18.845)
That's the thing for me that that's what made me.

Dr Claire Macaulay (45:19.086)
So we need to put these things in context. Being overweight is four times the risk of having breast cancer or developing breast cancer.

using HRT. So we need to understand that yes there is a link and you know as an oncologist I'm not going to say there isn't. There is definitely from what we know currently and that may change with time because the types of HRT that we are using now are different to the types of HRT we've been using before but of course it takes studies of over 20, 25 years, 30 years to know about these links but from the basis of the data that we have now there is a

Dr Claire Macaulay (46:00.121)
among women who use HRT. So we need to be clear about that and anyone said it isn't actually telling the truth or doesn't really understand the data. So there is. But that risk is the same as your increased risk of breast cancer if you drink two glasses of wine a night. The risk of being overweight or obese is four times the risk of using HRT. So yes there are risks.

people need to understand what those risks. There is a brilliant infographic on this on the British Menopause Society website that shows you little dots of additional women in relation to breast cancer risk and all the things that we might do, being a beast, drinking, all those kinds of things. There is an infographic that can explain to people, maybe you can put that in the show notes if people want to look at it. So yes, there is a small increased risk, but everything that we do has a small increased risk. And I often say to people, okay, there is a small increased risk, but...

Laura (46:41.27)
It's fabulous actually that.

Dr Claire Macaulay (46:53.849)
and that risk is in the order of four and a thousand, so four additional women in a thousand will develop breast cancer over a lifetime. But there's a hundred percent chance that you're not sleeping tonight, and there's a hundred percent chance you're gonna have five hot flushes tomorrow. It's balancing up the here and now and what you'd experience and what your quality of life is against an increased potential risk.

and trying to find a way that people can feel comfortable with that. And everyone will have a different risk appetite. You know, everyone has a different way of looking at risk and assessing those risks for themselves. But make sure that you get some good quality information and then be able to weigh up for yourself whether those risks feel worth it to you or not.

Laura (47:33.398)
Yeah, and also maybe think about how you can counterbalance the risks by saying, you know, like for me, I take HRT, but I don't drink as much wine, because I want to take my HRT, and I want to remain as healthy as I can and I keep my weight, I'm a good weight. So it's about thinking about lifestyle choices as well, if that you can kind of use to balance.

Dr Claire Macaulay (47:39.165)
Yeah.

Dr Claire Macaulay (47:43.559)
Yeah.

Dr Claire Macaulay (47:49.914)
Yeah.

Dr Claire Macaulay (47:54.681)
Yeah, and the important, I think the important part about some of those things as well is that I see some of those lifestyle choices that you might make might actually resolve to some degree some of your menopausal symptoms. So we know that losing weight helps resolve, we know that drinking less alcohol helps people resolve their menopausal symptoms to a certain degree. So it's not an either or, you know, I often say this to people, it's not an either or. There is a woman actually on the Midlife Sex Festival who's a naturopath and a herbalist. And we talk about on that talk about, you know, irrespective of

Laura (48:05.216)
Yes.

Dr Claire Macaulay (48:23.693)
whether you're choosing to use HRT or not. Some of these things are also helpful for your general health. So it's not, you don't have to choose between your risks. You know, some of the risks, mitigating some of the risks for your breast cancer, for example, in terms of weight loss, alcohol intake, might actually help your menopausal symptoms as well, such that you might not need HRT. So it's about managing, it's about looking at it holistically and not imagine, and I see this quite a lot, you know, I see it.

you know, and this means that just managing your menopausal experience altogether, which is people think they're just going to stick on a patch and it's going to fix their shitty marriage and it's going to deal with the fact that they've got ailing parents or they've got wayward teenagers. You know, sticking on a patch isn't going to do any of those things. You need to assess your, I think this is a really important and exciting time to reassess your life as a whole and incorporate HRT into...

other things that you're also doing, like learning to say no and stop people pleasing and managing your time and managing your own periods of rest and all sorts of other things. Sticking hormones on isn't actually going to change your life, not really. Making a commitment to looking at this point of your life as an opportunity and a transition portal to make the best life you can for yourself, however long you've got left, is what matters.

Laura (49:33.662)
Absolutely, wow. I think that's really great. I think I feel like that's a really good place to sort of bring this conversation to an end. It's a really nice positive end to what's been a really interesting conversation. Thank you, Claire. It's been fascinating actually. And please, if you've enjoyed this, please subscribe and please leave a review. That helps this podcast to be found and so more people can listen to this conversation and more people can be helped.

Let's spread the word. And thank you, Claire, so much. I appreciate your time. And yeah, it's been lovely to have you.

Dr Claire Macaulay (50:08.289)
It's been an absolute delight. Thank you for having me, Laura.