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Great Sex at Midlife

  • 7 Ways to Connect, Stay Healthy and Feel Good

  • Whether we’re busy doing it or not, it’s probably on our minds. But maybe not like it used to be.

    Sex at midlife is complicated, after all. Hormonal changes, stress, fatigue and even that stubborn meno-pot sometimes seem to conspire against our best intentions to have healthy, intimate relationships. That’s why, MyLifeStages talked with our experts about overcoming the barriers – both physical and emotional – to great sex.

    As many happy couples already know, satisfying sex isn’t only for those 20-something whipper-snappers.

  • Get Honest with Yourself – and Your Doctor

  • How’s your sex life? Is it what you want it to be?

    In a 2004 study* of adults 45 and older, nearly half of women respondent’s reported dissatisfaction with their sex lives with reasons ranging from the lack of available partners to health concerns. At the same time, the majority of the study’s participants age 45 – 59 said sex was an important part of their lives.

    “Good sex is a huge quality of life issue,” says OB/Gyn David Eibling, M.D. “It affects the quality of our relationships, how we feel about ourselves and even the divorce rate. If you’re not enjoying sex, it’s important to ask why.”

    Eibling and other experts encourage women to talk openly with their doctors about the quality of their sex lives and any associated problems. Everything from chronic pain conditions and medications to hormonal changes can dramatically impact sexual relationships. A good practitioner can help sort through problems and explore solutions.

    “As a doctor, I’m very happy to experiment and ally with each individual patient to find out what works,” says OB/Gyn Leslie Hardy-Hood, M.D. “Everybody has their own unique issues. No one single person’s story is ever the same.”

  • Don’t Live with Discomfort

  • As women enter menopause, changes in the vagina can make sex downright painful. In time, the vagina loses elasticity and lubrication, becoming more vulnerable to tears and infection. Before menopause, a woman’s vaginal walls are approximately 18 cells thick, but after menopause those walls often atrophy to as little as one cell of thickness. Additionally, pelvic prolapse issues and related incontinence often become worse as the vaginal tissue breaks down and can no longer support the pelvic floor.

    According to Eibling, a constellation of hormonal downshifts hit women during midlife:

    • Testosterone, the male hormone that drives libido, decreases.
    • Estrogen, the female hormone that, among many things, prepares the body for conception and pregnancy, also decreases.
    • Progesterone, the regulator of our menstrual cycle, drops as well.

    Although some middle-aged women say sex over 40 is better than ever, others find themselves avoiding it altogether.

    “For some, sex just isn’t worth the trouble,” explains Eibling. “With things like loss of libido, soreness and frequent bladder infections, there’s just not going to be a lot of satisfaction.”

    That’s the bad news. The good news is that women don’t have to live with this scenario. Hardy-Hood advises her patients to try over the counter lubricants for mild to moderate dryness, as well as general lifestyle improvements to boost overall health. For example, losing weight, treating chronic coughs and practicing pelvic floor exercises (kegels) can help relieve pelvic pressure that causes incontinence and some sexual discomfort.

    Still, she sees many women who are beyond basic treatment.

    “Kegels are usually not helpful in women with significant prolapse or incontinence.,” says Hardy-Hood. “Often, by the time a patient complains about incontinence, they’ve had enough. They’ve tried enough.”

    Women with incontinence problems, should be evaluated by their OBGyn or a urogynecologist, doctors who specialize in pelvic floor issues, to discuss surgical options, including minimally invasive laparoscopic procedures.

    When vaginal symptoms like dryness and discomfort continue to be a concern, hormone replacement can help. According to Eibling, hormone replacement creams applied directly to the vagina can dramatically rejuvenate and protect vaginal tissue.

  • Keep an Open Mind About Hormone Replacement

  • In 2002, the Women’s Health Initiative Study came to a screeching halt when older participants taking hormones showed an increased risk for heart disease, rather than the previously assumed decrease risk. For a while, many women and their doctors shunned hormones altogether, deeming the therapy too risky. In recent years, however, the study’s methodology has come into question, paving the way for a new middle ground approach to hormone replacement. (For more on the hormone controversy, read The Latest on Hormone Therapy: The Last Resort?)

    Today, the prevailing belief among many health experts is that hormone therapy remains the most effective way to treat menopausal vaginal symptoms but if used, should be given in the lowest dose possible for the shortest amount of time. The key is for women and their doctors to carefully weigh risks and benefits on an individual basis.

    “The WHI study got everyone concerned about heart attack and stroke, but they didn’t ask important quality of life questions, such as do these women sleep? Do they have sex, and are they continent?” says Eibling.

    Although hormone replacement isn’t for everyone, many women with menopause-related vaginal symptoms benefit from topical hormone treatments such as Premarin creams and Estring, a slow-release estrogen ring that is inserted into the vagina. According to Maxine Barish-Wreden, M.D., a Sutter Medical Group internist specializing in complementary and integrative medicine, the topical treatments provide greater relief than traditional oral supplements but with a lower dose of hormones.

    “They can be applied directly to the vaginal tissue, so the hormones get right to where they’re needed,” she says. “That way we don’t need as high of a dosage as a pill that has to go through the entire body” she says.

    Since vaginal atrophy and dryness can lead to other health problems, like increased risk for urinary tract infections and even STDs, women with vaginal symptoms should look carefully at trade-offs in the larger context of life quality and overall well-being.

    “Every choice that we make has a risk and a benefit, whether you do nothing at all or whether you choose to take medication,” says Barish-Wreden. “If you knew you only had one year to live, would you avoid using any hormones to keep yourself safe, or would you take care of your sexual health now so you could look back and say, ‘Damn, I had great sex!’?

    “We can get really stuck on the whole longevity thing, worrying about every risk factor we have and trying to keep ourselves safe, but at the same time robbing ourselves of the pleasure of the moment.”

  • Use It or Lose It?

  • Like all muscles, the vagina needs regular exercise to stay strong. Regular intercourse helps the vagina maintain tone and lubrication, reducing the severity of menopausal atrophy and dryness.

    “I see a big difference between women who have steady partners and those with episodic partners,” says Eibling.

    Problems often occur in women who, for a variety of reasons, haven’t had intercourse for months or years. During a midlife hiatus from sex, a woman’s body may have changed without her realizing. When sex resumes, she may find the whole experience to be much more uncomfortable than it used to be.

    And then there’s the little blue pill.

  • Practice Patience with Each Other

  • Viagra has changed the midlife sexual landscape, creating both the opportunity and the pressure to have sex later in life. For women, the joy of re-connecting with their partners is sometimes overshadowed by resulting injuries.

    “I can’t tell you how many postmenopausal women end up with tears in their vaginal tissues once their partners start using Viagra,” says Eibling. “It wasn’t until the last century that people lived much past 50. In some ways, we’re dealing with an artificial lifespan, so we sometimes need artificial help to keep doing the things we want to do.”

    Barish-Wreden, encourages partners to be patient with each other. If sex hasn’t happened in a while, take it slowly. She advises letting go of taboos and exploring whatever works.

    “Orgasm is an important way to lubricate the vagina,” she says. “If you’re having difficulty, try a vibrator, read a junky romance novel, whatever it takes!”

    Sex may not be what it was at age 25, but it has the potential to be something new and even better. As older children leave the house, and pregnancy becomes less of a concern, many women find midlife to be a time of great sexual freedom.

    According to one MyLifeStages member:

      I really didn’t appreciate my own sexuality during the earliest years of my marriage (too insecure, too inhibited), and certainly not during the period of pregnancy, birth and raising children (since my focus was on those things).

      In fact, it wasn’t until I reached my 40s and had my own “midlife evaluation” that I began to appreciate my body, appreciate men, and appreciate sex. And after menopause, with the threat of pregnancy gone and the responsibilities of parenthood greatly lessened, I’ve experienced the best sex ever.”

    “A fair number of my patients have consciously decided to embrace the changes and don’t have a lot of problems,” adds Hardy-Hood. “There’s a lot of freedom in leaving the childbearing years.”

    Until a woman has gone through menopause, however, there is always that slim possibility of pregnancy. For women in long-term monogamous relationships, Hardy-Hood recommends low-dose oral contraceptives, birth control implants like Implanon, and the Mirena IUD, a five-year time-release intrauterine device. Mirena contains a progesterone that suppresses the growth of the endometrial lining, which can put an end to irregular, waning periods.

    “Mirena is an especially good option for perimenopausal women,” she says. “For women who have on and off periods and are ready to be done, it can stop them altogether without the concerns of hormone replacement.”

    Eibling is also a fan of new outpatient female sterilization options, which use springs to form plugs rather than actually “tying the tubes.”

    Eibling encourages women and men to consider the other’s experience, both physically and emotionally.

    “Men are being told that they need to have frequent ejaculations in order to prevent prostate cancer, and they have Viagra pushed at them left and right,” he says. “Women meanwhile want to have a close relationship with their partners but may avoid sex because it hurts. If we understand what’s going on, we can find ways to move forward.”

  • Focus on Today, Not the Past

  • Truth is, vaginal problems and erectile dysfunction aren’t the only reasons we’re not having sex.

    Some women feel as though menopause casts a sort of asexual shadow over their lives as they struggle with what it means to be a woman past childbearing years. Add midlife weight gain and wrinkles to the equation, and self-esteem issues can become a real problem.

    “For women, the majority of sexual interest and libido is in the brain and not necessarily in the body,” says Hardy-Hood. “Maintaining sexual interest involves enlisting a strong mind and body connection.”

    From time to time, Hardy-Hood encourages her patients to seek the help of a personal trainer, or even a therapist, to proactively address body issues. Even more, she advises her patients to focus on their bodies as they are today not what they were 20 years ago.

    “Take into consideration who you are now and embrace the wisdom and experience that you’ve gained along the way,” she says. “Becoming comfortable in that skin is essential to enjoying your relationships with yourself and your partner.”

  • Set Clear Intentions

  • Fatigue, stress and modern life’s many distractions also take a toll on a healthy sex life. But midlife brings new opportunities for couples to reconnect after years of focusing on family and careers.

    Barish-Wreden encourages women to look at the big picture of what they want from their intimate relationships. “How do you want to re-create that relationship again and create romance in your lives?” she asks.

    Or, if you’re in a state of relationship transition, what kind of relationship do you want in your life? If sex is an important piece of the equation, create a deliberate intention to cultivate a rewarding sex life, starting with self-talk.

    “Notice the language that you use,” says Barish-Wreden. “What we tell ourselves over and over is what we create. So if we’re telling ourselves that we’re too tired and too stressed to have sex, that’s what we create.”

    Instead, visualize a great sexual relationship. What would that look like? As a starting point, Barish-Wreden advises couples to schedule time together doing what they love.

    “What can you move towards or bring into your life that brings you joy, connects you with your senses and connects you with your partner?” she says. “It’s those moments when we’re in the flow – together that naturally lead to and enhances our physical intimacy.”

    * AARP

Ask our experts your sexual health question(s).