Strategies for Staying Sexual After Menopause
Taken from the March/April 2009 issue of the Women's Health Activist Newsletter.
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 Niagra — 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.
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.
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 non-prescription Replens® (a non-hormonal lubricant) may provide sufficient relief.1 Some women turn to medical treatment and use 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 at http://www.fwhc.org/ sale3.htm#plainspec.
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 sur-gical removal of the ovaries (i.e, due to cancer, endometriosis, uterine prolapse or other reasons) can cause these changes to be sudden and sometimes devastating. Numerous drugs, especially 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 in sex.
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.2 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 Sexual, below.
Involuntary loss of urine can occur at any age but, after the age of 65, 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 effects of some medications, and pelvic surgery (especially hysterectomy).
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.3 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 NWHN’s fibroids fact sheet at https://www.nwhn.org/healthinfo/detail.cfm?info_id=5&topic=Fact%20Sheets). 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.
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.4 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 with The Ultimate Guide to Sex and Disability: For All of Us Who Live with Disabilities, Chronic Pain, and Illness.5
Masturbation 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!6 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 U.S. is over the age of 50 (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 pleasure.
There are countless websites devoted to sex and aging that provide information on every conceivable topic. Long-time NWHN member Betty Dodson, a very youthful 80, is celebrating 40 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 (www.dodsonandross. com). 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 (see: http://www.stilldoingit. com/ index.html).
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 (www.babeland.com), Good Vib-rations (www.goodvibes.com), and Eve’s Garden (www.evesgarden.com) have especially wide selections.
If these strategies aren’t sufficient, you might consider seeing a sex therapist. One source for a trained therapist in your area is the American Association of Sexuality Educators, Counselors and Therapists’ website (www.aasect.org). 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.
Dealing with sex issues can be a daunting proposition, and many of us might prefer to sweep them under the carpet and read a book, finish a report, or paint the bathroom — anything that doesn’t cause such anxiety and frustration. But, as I’ve indicated, many solutions are available — so be pro-active! Sexuality and sexual expression are among life’s greatest gifts, and are ours to explore, tweak, enhance, and enjoy, on any level that is possible and comfortable. Whether you are alone or with a partner, good sex — by your personal definition — can enhance health and self-esteem. It’s not just the province of the young and agile!
Rebecca Chalker is the author of The Clitoral Truth: The Secret World At Your Fingertips. She teaches an online seminar on “The Cultural History of Sexuality from Prehistory to the Present” described on her website: www.clitoraltruth.com.
The continued availability of external resources is outside of the NWHN’s control. If the link you are looking for is broken, contact us at email@example.com to request more current citation information.
1. Van der Laak, JA, de Bie LM, de Leeuw H et al, “The Effect of Replens® on Vaginal Cytology in the Treatment of Postmenopausal Atrophy: Cytomorphology Versus Computerised Cytometry,” Journal of Clinical Pathology 2002; 55(6): 446–451.
2. Ferguson, JM, “SSRI Antidepressant Medications: Adverse Effects and Tolerability”, Primary Care Companion, Journal of Clinical Psychiatry 2001; 3(1): 22–27.
3. See “Kegel Exercises: How to Strengthen Pelvic Floor Muscles” at: http://www.mayoclinic. com/health/kegel-exercises/WO00119.
4. Loulan JoAnn, Lesbian Sex, Midway, FL: Spinsters Ink, 1984.
5. Kaufman M, Silverberg C, and F Odette, The Ultimate Guide to Sex and Disability: For All of Us Who Live with Disabilities, Chronic Pain, and Illness, San Francisco: Cleis Press, 2007.
6. Giorgi G, Siccardi M, “Ultrasonographic Observation of the Female Fetus’ Sexual Be-havior in Utero,” American Journal of Obstetrics and Gynecology 1966; 175: 753.
Barbara Seaman’s Sexuality Activism
Readers of the Women’s Health Activist will be intimately familiar with Barbara Seaman’s work on hormones and women's health. Less well-known is her early interest and activism on sexuality. From the mid-1960s, Barbara wrote columns on marriage, family, and sexuality for Lady’s Home Journal, Family Circle, and Bride’s magazine. In 1970, after a change in management, Barbara and other feminists at Brides’ were fired and she was ripe for a new project. She took the material from her Bride’s columns and turned it into Free and Female: The Sex Life of the Contemporary Woman, the first feminist sex advice book. In it, she predicted, “If there is going to be a breakthrough in human sexuality — and I think that such a breakthrough might be in the wind — it is going to occur because women will start taking charge of their own sex lives.” To this end, she audaciously proclaimed, “The liberated orgasm is any orgasm you like, under any circumstances you find comfortable.” A brief excerpt from Free and Female was published in the inaugural issue of Ms. in June, 1972. Barbara urged me to document the history of feminist sexuality activism, a project that is now underway. It saddens me that she won't be here to see the finished product.