This article was first published in the Women’s Health Activist.
When was the last time you
heard a joke suggesting that sex invariably goes ever downhill or totally
crashes after menopause? Like yesterday? This concept was boldly reaffirmed – without
reference to reliable research – at a conference on menopause held by
the National Institutes of Health in 2005! So, if you ask your doctor
about sex after menopause, she or he will likely agree that the outlook
is gloomy. On the flip side, the golden-years myth is heavily promoted
by TV ads for erection drugs, which portray the "Cialis woman" always
blissfully ready for intercourse whenever her partner drops a pill.
Fortunately, women’s health
advocates, sexologists, and researchers vigorously question these equally
unrealistic projections for sexuality and aging – of a bleak sexual
desert or a pharmaceutical Niagara – and have identified numerous helpful
strategies for maintaining and enhancing sexuality after menopause.
Here’s a survey of some of the most common problems and strategies
to help make sex during this life phase more comfortable and rewarding.
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By far the most common sexual
problem that women report in their post-reproductive years is dyspareunia – pain
or discomfort during or after intercourse or insertion of fingers or
sex toys into the vagina. After menopause, reduced levels of the hormones
estrogen and progesterone result in less natural lubrication that may
result in bleeding, tightening of the vaginal opening, and/or narrowing
and shortening of the vagina. All of these can make intercourse uncomfortable
or even intolerable.
Solutions: Many women and sex
therapists report the reality of the use-it-or-lose-it factor: regular
sex, either with a partner, through masturbation, or a combination of
the two, definitely helps keep vaginal tissues more supple and moist.
Extended sex play before insertion is always helpful even if discomfort
isn’t severe. Liberal use of a water soluble lubricant is often enough
to make intercourse more comfortable. Having intercourse after a long
time without it can be painful or impossible, but don’t give up. You
may need to work up to it. Over a few weeks, the vaginal opening can
be comfortably stretched using lubricants and successively larger blunt
objects such as vibrators or dildos, or a set of vaginal dilators (available
without a prescription at medical supply stores). Alternatively, daily
use of nonprescription Replens (a nonhormonal lubricant) may provide
sufficient relief. Some women turn to medical treatment and use a small
amount of low dose estrogen cream applied at the opening and inside
of the vagina. Women who have a personal plastic speculum may find looking
inside the vagina helpful to assess the normal appearance of vaginal
tissues and to monitor response to self-help or medical remedies. You
can order a speculum from the Feminist
Women’s Health Centers.
Low or Absent Sexual Desire
Many older women also report
slower response to mental or physical sexual stimulation; a longer time
to become sufficiently aroused; or, in severe cases, a total lack of
interest in or revulsion to sex. Decreased interest in sex may be temporary
or long term, but surgical removal of the ovaries (due to cancer, endometriosis,
uterine prolapse, or other reasons) can cause these changes to be sudden
and sometimes devastating. Numerous drugs, especially selective serotonin
reuptake inhibitors (SSRIs), are known to cause reduced sexual interest.
On top of this, the lower systemic availability of testosterone, the
key promoter of desire in both women and men, can cause less interest
Solutions: First, ask your
doctor to review all of your medications and discontinue any that are
not essential. For certain medications, taking a "drug holiday"
on weekends, or for a few days during a vacation, can be helpful if
your doctor approves. The SSRI citalopram (Celexa) is reported to have
a lower negative impact on desire, so switching to it may be an option.
If you have a partner, it’s important to talk about lower sexual interest
so that he or she does not feel that sexual coolness is personal. In
addition, you can use any of the suggestions in Strategies for Staying
Involuntary loss of urine can
occur at any age but, after the age of sixty-five, 10 percent of the
population experiences mild to severe leakage. There are different types
of incontinence, but by far the most common in women is stress or "giggle"
incontinence, in which sudden movements or vigorous activity – such
as sex – can result in leaks. Urinary leaks can be disconcerting, and
the possibility of this happening during sex can cause some women to
avoid partner sex altogether. Primary causes of urinary incontinence
include changes in bladder position after vaginal childbirth, lax pelvic
muscle tone, involuntary bladder contractions (called "overactive
bladder"), the usage of some medications, and pelvic surgery (especially
Solutions: The gold standard
of incontinence treatment is pelvic floor muscle exercises, commonly
called "Kegel exercises," after Dr. Arnold Kegel, who researched
and popularized them in the 1950s. Doing these exercises several times
a day may be all that is needed to check surprise leaks. A common myth
is that Kegels don’t work. They do, especially for mild to moderate
urine loss. And the huge plus of well toned genital muscles is the possibility
of having more intense orgasms! If doing Kegels on your own does not
improve continence, a biofeedback program can be very effective in strengthening
continence muscles and monitoring progress. (Sometimes biofeedback is
covered by insurance.) Biofeedback can be combined with bladder retraining,
which helps you hold urine comfortably for longer periods of time. In
addition, several medications are available to control overactive bladders.
Pelvic surgery can result in
a host of dramatic changes in sexuality. This is particularly true for
hysterectomy, especially if one or both of the ovaries are removed.
Cancer is the only absolute medical indication for surgical removal
of the uterus and/or ovaries, so if your doctor recommends hysterectomy
for any other reason, definitely seek a second opinion. Until recently,
hysterectomy was the recommended remedy for uterine fibroids, but newer
techniques are now available that preserve the uterus. (See the National Women’s
Health Network’s fibroids fact sheet.)
Sexual changes associated with hysterectomy, as with menopause in general,
may include vaginal dryness, reduced or lost sexual desire, noticeable
changes in time to orgasm, less intense orgasms, and loss of ability
to have multiple orgasms.
Solutions: See the suggestions
for alleviating vaginal dryness and loss of desire noted above and Strategies
for Staying Sexual, below.
Strategies for Staying Sexual
In addition to the techniques
suggested here, many women use a variety of self-help solutions to enhance
their interest in, and comfort during, sex. Heterosexual women and lesbians
certainly have the same problems, but lesbians may find it easier to
negotiate solutions because their partners may have similar issues.
If intercourse is painful and/or male partners don’t get erections
readily, consider taking the focus of sex off of intercourse and indulge
in the much heralded pleasures of outercourse, which includes every
sexual activity except penis-in-vagina sex. If orgasm isn’t as reliable
as before, why not make pleasure the goal of sex rather than orgasm?
Sex therapist JoAnn Loulan asserts that sex should begin with willingness
and end with pleasure, with or without orgasm in between. It’s the
brain, anyway, not the genitals, that’s the chief sex organ, so starting
there should be key to sexual enhancement. Rewarding sex can be as simple
as cuddling, trading sensual massages, sharing fantasies, genital stroking,
or watching or reading erotica alone or together. If the genitals respond
to such activities, whether or not they are touched, it’s still sex!
Many sex therapists recommend the use of filmed or written erotica to
encourage sexual interest, and erotic material is readily available
for every taste and interest. In addition, there is a wealth of sexuality
self-help material in books, magazines, and on the Internet. My personal
favorites are sexual techniques based on the ancient Asian traditions
of Tantra and Tao, which take the focus off of the genitals and use
ritual, extended sex play, and full body sexual stimulation to create
more intense sexual response. Books and workshops by Margot Anand are
particularly popular. For those with more serious disability issues,
there are several excellent books on sex and disability; you might start
Ultimate Guide to Sex and Disability: For All of Us Who Live with Disabilities,
Chronic Pain, and Illness.
isn’t just a crutch to use in place of partner sex. It is a self-affirming
sexual activity and is eminently useful in helping to discover different
routes to sexual pleasure. In national studies, up to 40 percent of
women report that they masturbate on a regular basis, but this incidence
may be lower for older women. Many older women may remember being discouraged
(or even punished) for masturbating as children, and may still be reluctant
to engage in this pleasurable sexual activity. Ultrasound images have
captured male and female fetuses masturbating in the uterus; these images
confirm that masturbation is an innate and entirely normal part of sex!
Safer Sex: The explicit truth
is: regardless of age, in partner sex, we are all at some risk for contracting
a sexually transmitted infection (STI), including HIV/AIDS. In fact,
one in ten people diagnosed with AIDS in the United States are over
the age of fifty (although transmission rates are much lower among lesbians
than among gay men and heterosexuals). Discuss a new partner’s sexual
history, keep condoms handy, and don’t take any risks. Outercourse,
as described above, greatly reduces the risk of STIs, without reducing
Websites: Countless websites
devoted to sex and aging provide information on every conceivable topic.
Long time NWHN member Betty Dodson, a very youthful eighty, is celebrating
forty years of helping women explore and enhance their sexuality. Recently,
Dodson teamed up with Carlin Ross to build a new interactive
website that provides
resources on a wide array of topics. Dodson also appears in Still Doing It:
The Intimate Lives of Women Over Sixty,
a film and book of the same title by Deirdre Fishel and Diana Holtzberg.
Women-friendly Sexuality Boutiques:
Incorporating sex toys, especially vibrators, into masturbation or partner
sex can be extremely helpful in altering sexual routines. All sexuality
boutiques have extensive online and printed catalogs to enable shopping
in the privacy of one’s own home. For a start, Babeland, Good
Vibrations, and Eve’s Garden have especially wide selections.
Sex Therapy: If these strategies
aren’t sufficient, you might consider seeing a sex therapist. One
source for a trained therapist in your area is American Association
of Sexuality Educators, Counselors and Therapists‘ website. Your therapist can help
you sort through feelings about sex and aging, issues with a partner,
or medical conditions that impact on sex, and she or he can make additional
suggestions about how to cope with other problems and can suggest additional
strategies for staying sexual.
Life Changes that Impact
Clearly, there are many ways
to cushion or fix the physical changes that may occur after menopause.
But truth be told, changes in relationships, as well as complex life
situations caused by diminished income, divorce, illness, or death can
be vexing and more difficult to resolve. Such changes can deprive us
of the comforts and intimacy afforded by sex in a long term relationship,
or for many women, they might provide the opportunity to explore new
sexual possibilities where rewarding sex has been lacking.
"Good sex" is different
for many people and in later years, many are happy to say goodbye to
the hormone driven sex of their youth and live with "good enough"
sex that focuses on emotional and quiet physical pleasures, which may
or may not include orgasm. The key here is to identify what is pleasurable
for you and then look at what is possible given your situation.
Traditionally, "sex" has
been defined as heterosexual intercourse, but feminists and sex educators
have successfully redefined sex to include any activity that results
in sexual pleasure. With a partner, as noted above, we always have cuddling,
petting, kissing, sharing fantasies and stories, bathing together, dancing,
even dressing up and playing games! And don’t forget about adding
sex toys to your repertoire.
For those who are single (I
like to think of it as "independent"), the possibilities for new
connections and friendships are there for the asking. Joining an interest
group is an easy way to slip into a new social current. Take a class.
If you can afford it, take a cruise. Volunteer! Visit a larger congregation.
Others in similar situations are seeking partnerships too!
If fetuses can masturbate in
the uterus, and we know that they do, then, at the most basic level,
we are sexual throughout our lives. Sexuality is a part of our humanity;
it’s why we are here today. Menopause may reduce our reproductive
hormones, but it does not rob us of our sexuality. It’s still there
to be relished, enjoyed, and, perhaps, shared.