Midlife and Menopause
Sexual Issues in Menopause
Women sometimes wonder what is in store for our sex lives as we enter menopause. In our society men continue to be seen as potential sex partners until an advanced age, but women are commonly considered to be over the hill by midlife.
Medical textbooks claim that women's sex drive increases with menopause, when we no longer fear getting pregnant. Feminists and women's glossies insist that all you need is the right attitude, and your sex life will flourish forever.
Hormone therapy in menopause is now on the outs with the medical community. It has been shown that so-called hormone replacement therapy (a term cleverly coined to emphasize its "naturalness") does not prevent coronary artery disease and seems more likely to cause than to prevent other life-threatening diseases.
But women continue to ask whether hormones can improve the quality of our lives even if they can't prolong it. These issues are virtually ignored by the medical literature.
In fact, many women sail right past the menopausal transition. But others find, often to our surprise, that we do experience sexual difficulties. It can be difficult to find help or even validation for several concerns:
Loss of libido
Though women's sexual functioning and enjoyment of penetration commonly peaks in our forties, it's true for both men and women that the intensity and the impelling quality of the sex drive fall steadily after adolescence. An additional dip is frequently experienced with the menopause, and can be profound.
Impaired sexual functioning
Sexual encounters may change in quality because of decreased pleasure with penetration, difficulty reaching climax, weak orgasmic sensations, etc. Even before menopause, many women stop feeling the need to have an orgasm with every sexual encounter.
Changes in world view
Some menopausal women find ourselves losing interest not only in sex per se but in the entire romantic, passionate, or flirtatious side of human interactions.
Estrogen lack inevitably causes the vaginal lining to become thinner and dryer, which causes pain and difficulty with penetration for most, though not all, women.
Sexuality can be affected by the mood swings of early menopause, the symptoms of the menopausal transition, the physical effects of hormone lack and the way we and others see menopause.
Women wracked with anxiety from hormone swings, soaked with sweat from hot flashes, or in what feels like a constant state of premenstrual tension are unlikely to be feeling very sexy. Once the ovaries have stopped putting out hormones, vaginal dryness can make penetration unappealing. And the symbolic value of menopause can itself make us feel old, unattractive, and sexless.
Do falling hormones kill libido?
Women's sex drive is related to hormones but in a complex way: the female hormones, estrogen and progesterone, have less of a stimulating effect than the male hormones, which are secreted in small amounts by the ovaries. In fact most menstruating women feel sexiest immediately after our period, the time of the month when female hormones are at their lowest level. When the ovaries cease functioning with the menopause, they stop producing both male and female hormones, which affects some women's sex drive. Eventually the adrenal glands take over to some extent, especially in producing male hormones, and the sex drive can then perk up again. But this is not inevitable, and some women experience even a temporary plunge in our sexuality as devastating.
Strategies for coping:
The vaginal tissues
Vaginal dryness is the first, and easiest, thing to fix if you are experiencing sexual difficulties. Often saliva, K-Y jelly, or Astraglide (a long-lasting vaginal available in the United States) give sufficient relief. When they don't, tiny amounts of estrogen creams applied vaginally will not only improve lubrication but will after a few weeks restore the thickness and consistency of the vaginal area to its pre-menopausal levels without exposing the rest of the body to hormones. Simply making penetration painfree and well-lubricated can bring back sexual pleasure for many women.
When a woman's sexual functioning remains unsatisfactory even after her vagina regains its juiciness, systemic estrogens in the form of pills or patches can be tried. If this treatment works, as it often does, it can be continued at the lowest effective dose following the standard precautions for hormone therapy, with the addition of progesterone to protect the uterus, and planning periodic pauses to see whether it is still necessary.
Male sexual hormones can effectively boost a woman's flagging libido, either in association with estrogen (Estratest, a pill combining estrogen and testosterone, is available in the United States, or by themselves. But male hormones can deepen a woman's voice and cause liver damage, among other side effects, so they are probably not a good solution for other than the short run.
Sold as Livial in much of Continental Europe and, as of 2002, in the United Kingdom, but not yet available in the USA, this molecule combines some of the effects of estrogen, progesterone, and testosterone. It is fairly effective for hot flashes and vaginal dryness and very effective for reviving the sex drive. Tibolone is less masculinizing than testosterone and probably provokes less breast cancer and uterine cancer than usual hormone replacement therapy; its effects on heart disease are unknown.
You may even find in the end that a decreased interest in the sexual side of life, though initially disconcerting, is unimportant or even welcome. After decades being driven by our sexuality many women find the calming of the senses that can accompany menopause to open us up to a new independence and to enthusiasm for exploring new interests during the second half of our adult life. The menopausal Germaine Greer, previously known for her sexual exploits, amazed some of her fans by extolling the joys of gardening. Other women say, "My sex life is better than ever -- since menopause we do it twice a day." Few phenomena in the life cycle vary as much as the menopause.
It is not only women who encounter changes in our sexuality with aging. Older men often require more direct stimulation to attain an erection, and have a longer "refractory period" between ejaculations. For many couples, heterosexual and homosexual, the sexual encounters of later life, richer in snuggles and gentle caresses and less focussed on orgasm, can be at least as rewarding as those of their youth.
Written by: Susan Levenstein, MD
Last revised: December 2002
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