Women's Health Concern

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Sex after the menopause

By Eike Adams

Sexuality in all its forms can be an important part of your health and identity. However, in western societies sexuality is often considered the domain of the young, and the idea of older women having and enjoying sex sits uncomfortably with many people. It is only since the work of Kinsey and other sexuality researchers in the late 1940's, that perceptions of older people's sexuality started to change. But it is still the case today that it is more acceptable for older men than older women to be sexual. The ideas of older women's sexuality often stem from Victorian times, where the woman was passive in her sex life, and sex was mainly for reproductive purposes 10. Hence, the idea was that sex would stop after the menopause.

The menopause is often described as a very negative time for women, especially in medical literature. On the other hand, many feminists and women-centred writers celebrate the menopause and subsequent years as a time of positive change, without the commitment to childrearing, and a time to find new fulfilment. The experience for each individual woman is probably somewhere in the middle. Hormonal changes in the menopause, such as a drop in oestrogen levels (oestrogen is the ‘female' hormone responsible for development of female characteristics) within your body, can bring about physical changes such as vaginal dryness, which can affect your sex life 2. But at the same time, there are many ways of adjusting to these bodily changes that can lead to new ways of lovemaking.

This article will discuss some of the myths surrounding older women's sexuality, some of the changes that might occur during and after the menopause, and give some tips on how to maintain a good sex life in your later years.

Myths

Many myths surround older women having sex, which might contribute to them feeling unable to express their feelings and desires when it comes to sexuality, for example:

"Women stop having sex after the menopause"

Sex is linked to youthfulness, and a woman is often portrayed as desirable and desiring only if she has a slim and youthful body. It follows that older women whose bodies have changed are often perceived as not having sex at all! However, research has shown that many older women have sex as often as they used to in their forties and that in actual fact, for many different reasons, sex often gets better in later life and women feel more fulfilled. In many indigenous societies, this is far more recognised, and older women often play the role of sexual initiator or instructor for young men 4.

Another myth is:

"Women have a lack of libido (stop wanting sex) after the menopause"

It is true that some women want less sex as they get older. But this is not the case for all women. One reason might be that physical symptoms from the menopause such as hot flushes or vaginal dryness reduce your desire for sex. However, for some women the opposite is true. You might have an increased libido (desire for sex) when you get older, and the way you have sex might change. Limited research suggests that in later years, penetrative sex might play a lesser role, and foreplay, sensual play, or masturbation might become more important. There is no age limit for sex, and most women continue in older age what they used to like doing when they were younger. That means if you enjoyed having sex it is most likely you will continue, but if you didn't enjoy it, you might be relieved to stop after the menopause.

So overall, your sex life doesn't have to stop after the menopause. In fact, the opposite might be true and you might enjoy yourself more than ever! It's about time those myths were laid to rest, and in the following we will look at some of the facts related to sex after the menopause.

Bodily changes during and after the menopause

When you get older, your body produces less oestrogen, which means that the skin all over your body changes. The skin inside the vagina will also become less elastic and dryer. Your vagina changes in shape, becoming shorter and often narrower, and you might lose some pubic hair. However, these changes are different from woman to woman, and they are not necessarily dramatic, or very noticeable. On the upside, many women report that they enjoy not having periods anymore, which increases their desire for sex.

Physical complaints and sexuality

Having an illness or a physical disability does not mean that your sex life has to stop, but unfortunately, many health professionals do not discuss sexuality with older women as a matter of course, and in that case you might have to take the initiative and ask your doctor for help

Self-help

Your doctor or practice nurse should be able to advise on self help.

Vulval discomfort

When you get older, your body produces less oestrogen. This can cause vaginal dryness, which means that sex might become less enjoyable or even painful. In extreme cases, your vaginal wall might tear, which can cause some bleeding. The acid/alkaline balance in the vagina also changes towards being more alkaline and less acidic, which means that it can become sore more easily, and is more prone to infections. This condition is also called atrophic vaginitis.

Self-help

Having different forms of sex, and being more playful with your vagina and clitoris (maybe stimulating them with fingers first), can increase the vaginal fluids and lubricate the vagina (make it wetter). You can also use a water-based lubricant such as KY Jelly, Astroglide or Replens. These are over-the-counter products, which are easily available from chemists or large supermarkets, and Replens is also available from your GP on prescription.

Homeopathic remedies such as Sepia can also help with a dry vagina, but you should seek the advice of a qualified practitioner.

Medical treatment

If the above measures do not help and your vagina is still dry, your doctor might prescribe you hormonal treatment. In most cases this will be an oestrogen cream, which is applied to the vagina and the vaginal walls directly and increases the flow of natural lubrication. This oestrogen cream is not a lubricant like KY Jelly; it works through the hormones (oestrogen) that are applied onto your skin directly. In some cases the cream may not be effective and you should discuss possible alternatives with your doctor.

Urinary Tract Infections (UTIs)

When a woman's vaginal walls become thinner because of lower levels of oestrogen in her body after menopause, penetrative sex can not only cause vaginal discomfort, it can also cause urinary irritation or urinary tract infections. This is because the urethral passage (from the opening up to the bladder) also thins. Penetration might irritate the bladder and the urinary tract through the thin walls of the vagina. This irritation can lead to infections. Additionally, because the alkaline/acid balance in the vagina changes (see section on vulval discomfort), a higher number of bacteria can settle in the vagina and cause urinary tract infections. Symptoms include an urge to make frequent visits to the toilet, pain or difficulty in passing urine. Frequent urinary tract infections can be a sign of atrophic vaginitis (inflammation and/or skin changes of the vagina caused by lower levels of oestrogen, see above under vulval discomfort).

Self-help

For prevention, a sensible hygiene regime is important, meaning that you can clean, but don't ‘over-clean'. After using the toilet, always wipe from front to back, i.e. from the vagina to the anus, not the other way round. This prevents bacteria being carried from your anus to your vagina. Also, using water is sufficient – perfumed products are often too harsh. Do not douche or scrub, but wash your vagina and anus gently.

Self-help measures for dryness of the vagina are described above under vulval discomfort. It might also be helpful to try different sex positions, which give you more control. For UTI s, drinking plenty of water may help to keep infections at bay (but it might make the problem worse if you already have UTI). Adding a bit of bicarbonate of soda to the water might also help, as it will alkalise the urine and ease the pain. Cranberry, either in tablet form or as cranberry juice is also very good as a urinary antiseptic (try to use juice varieties with less sugar; you might be able to get them from a health food shop). Paracetamol will reduce the pain, and can keep down any fever you might develop.

Medical treatment

Oestrogen cream will increase lubrication, but it is a hormonal product and might have side effects that need to be considered before using it. For the urinary tract infection itself, the doctor will probably prescribe a course of antibiotics.

Sexual health: Sexually Transmitted Infections (STI) and AIDS

Articles and books on STIs hardly ever talk about older women specifically, but STIs as well as HIV/AIDs are on the increase in older women. This might partly be because women after the menopause do not need to use birth control, and therefore also do not use protection such as condoms anymore. If you have had the same partner for many years, and your partner has also not had any other sexual partners, the risk of getting a sexually transmitted infection is low. But if either you or your partner has unprotected sex with anyone else, the risk is increased. This is the case in both heterosexual and lesbian relationships. There are many different STIs, and some of them do not have any symptoms. However, if you notice any unusual or smelly discharge from the vagina, bleeding, blisters, itches, pains or sores, you should go to a sexual health clinic, also called Genito-Urinary Medicine (GUM) clinic, to get it checked. (For further information on Sexual Health, see our Factsheet)

Pelvic Cramps

Sometimes women may experience pelvic cramps during or after sex, especially women who have penetrative sex. It is more likely to happen if you do not have orgasms very often, and is generally nothing to worry about. Just like any muscle in the body, it can ache if it doesn't get used very much and then gets a lot of exercise.

Self-help

A warm bath might help to relieve tension and might ease the cramps, as might a hot-water bottle. If it is very bothersome, another way to relieve cramps is to stimulate yourself more often until you reach orgasm. The cramps should go away or at least become less painful.

Psychological changes

Sometimes, changes in the family can be difficult to adjust to when getting older, for example if your children leave home or you stop working and retire. It can help to talk with your friends and your partner about these changes and how they make you feel.

Because of the physical changes that occur as part of the aging process, it is possible that you may feel less comfortable with your body and that you lose some of your self-esteem. But again, these changes happen gradually, and many women adjust well to them.

However, if fatigue or psychological illnesses such as chronic depression or anxiety develop, they (and medications given for the latter) can interfere with your libido and sex life.

Medications and sexuality

As women get older, they are more likely to need long-term medications. Often, these medicines have side effects that influence libido, for instant blood pressure medications, and tranquillisers. However, alternative therapies might be available, and if you think that medication impacts negatively on your sex drive, speak to your doctor and ask if there is an alternative. Antihistamines and other drugs can cause drying of the vagina, and although this might not influence your libido, it might curb your enjoyment of sex (for self-help measures see section under ‘vulval discomfort').

The most widespread cause of drug-related sexual problems is in fact alcohol, because it can delay orgasm in women. This does not mean you should stop enjoying a glass of wine but regular consumption of alcohol over the recommended limit can have an effect on your libido.

Birth control

Women can become pregnant as long as they haven't reached menopause, and often think they are no longer fertile when in fact they still are. Your periods may become irregular or stop, but this is not necessarily a sign that you are infertile. It can be especially difficult for women on HRT to gauge whether they are already past menopause. Therefore, it is recommended that women who are not on HRT or hormonal contraception continue to use contraception for at least two years after their last period if they are under 50, and one year if they are over 50. For women on HRT it is recommended to use contraception (birth control) until the age of 55, because 95.9% of all women will have reached menopause by this age, and it is therefore relatively safe to stop 7.

Hormonal contraception

Hormonal contraception includes the pill (most common form of birth control) and the Mirena, an IUS (Intra-uterine Device) with progesterone. The pill can be either a combined pill, which contains both oestrogen and progestogen (a form of progesterone, which is a natural female hormone that is man-made for the pill), or a ‘mini pill', which contains only progestogen.

Women can use the combined pill up to the age of 50, unless they have a history of venous or arterial diseases, are at increased risk of hormonally related cancers, or smoke. However, the combined pill can mask menopausal symptoms such as night sweats or hot flushes, which might make it more difficult for you to work out whether you have reached the menopause or are still fertile 14.

If you are over 35 and you smoke, the combined pill can increase your risk of heart disease or stroke, and in this case you are often advised not to take this type of pill. However, you can still use the ‘mini pill' until you reach menopause. The ‘mini pill' is considered slightly less effective than the combined pill, but it also has fewer side effects.

Mirena is a form of hormonal contraception, and is useful if you want both HRT (relief from menopausal symptoms) and contraception. Mirena is inserted in your womb like any other IUD where it can stay for up to five years and releases a small dose of levonorgestrel, a type of progestogen. If used for HRT, the oestrogen component can be taken in tablet form, as patches or as a gel. Women who have not had a hysterectomy need progesterone as well as oestrogen in their HRT as it prevents their womb lining being over stimulated by oestrogen which can be a cancer risk. Any type of hormonal contraception can have side effects, which you need to consider before taking this type of contraception, and discuss with your practice nurse or GP.

Barrier methods

There are other methods, for instance barrier methods such as a diaphragm. Many women feel more comfortable with barrier methods because they only need to be used during sex. They can also be used with contraceptive foam or cream that provides extra lubrication, which might help you if you suffer from a dry vagina. However, diaphragms and spermicides (the creams used with the diaphragm) can cause a dry vagina and make you more prone to urinary tract or vaginal infections, and may therefore not be suitable for some women. Using condoms or the female condom has the added advantage that they protect from sexually transmitted infections (STI), which can be important if you or your partner have other sexual partners. Condoms are available free of charge from family planning clinics or GUM clinics.

Final thoughts

Many women actually enjoy sex more in later life, maybe because they are more experienced, and know what they want and enjoy. In addition, there may be more opportunity for spontaneous sex, for instance if you have children who have now left home. Overall, women in their late 40s are said to be much more likely to have fulfilling sex lives and multiple orgasms than women half their age 5.

Some research also suggests that when the oestrogen levels in your body drop, the ‘male' hormone testosterone (which is actually present in both men and women) might become more dominant and increase your libido 18. Testosterone has been described as the ‘sex engine' in both men and women 16, and research is underway to examine whether testosterone treatment might help women who have a lower sex drive to regain their libido. Currently, testosterone implants are sometimes offered to post-menopausal women to improve libido, but women's sex drive is complex and many different factors account for a woman's desire to have sex, which are not likely to be cured by a single medication. For women who have menopausal symptoms and low libido, Tibolone (Livial) which is similar to HRT is sometimes offered, as it has the effect of improving the libido.

Women's sexual response is thought to be different from men, and many women do not have ‘spontaneous desire', meaning it may not be until starting to engage in some sort of sexual activity that they start to feel sexual desire, and many women do not have any sexual feelings or thoughts, unless engaging in sexual activity. Because women's sexuality is so complex, it might actually be more appropriate to try and solve occurring problems with counselling first, rather than medications.

The assumption that women's sexuality is very complex and different to men's was confirmed recently by a maybe surprising source: Pfizer, the manufacturer of Viagra abandoned an eight-year long study involving 3,000 women in 2004, which was supposed to prove that Viagra improved sexual function in women. The leading researchers of the study conceded that ‘there's a disconnect in many women between genital changes and mental changes…with women, things depend on a myriad of factors' 20. Funny, that doesn't feel like too much of a surprise.

References

1 Booth C (2002) Woman to woman: A guide to lesbian sexuality, East Roseville New South Wales, Simon & Schuster

2 Boston's Women's Health Book Collective (1994).The New Ourselves, Growing Older, New York, Simon & Schuster

3 Culter, W (1991) Love Cycles, New York Villard Books

4 Davis E(1995) Women, sex and desire: Understanding you sexuality at every stage of life. Alameda,CA:Hunter House

5 Delvin D (1998) Sex and the mature woman. Menopause, 3(1), pp 4-5

6 EMIS (2005) Contraception and the mature woman. Retrieved from www.patient.co.uk/showdoc/40024661

7 Faculty of Family Planning and Reproductive Care Health Care Clinical Effectiveness Unit 2005; Guidance 2005;

Contraception for women over 40 years, Journal of Family and Reproductive Healthcare, 31(1), pp 51-64

8 Feltin, M (1987) A woman's guide to good health after 50. Illinois: Scott, Foresman and Co

9 Greengross, W and Greengross, S (1989) Living, Loving and Aging. London, Age Concern

10 Gott, M (2005) Sexuality, Sexual Health and Aging, Maidenhead : Open University Press

11 Gottlieb, A (1990) Lesbian Sex at Menopause:Better than Ever. Healthsharing, Fall/Winter pp21

12 Johnson,B (98) Older women talk about sex. Retrieved from www.selfhelpmagazine.com/articles/aging/eldersex.html

13 National Cancer Institute (2003) Oral contraceptives +cancer risk. Retrieved from http://cis.nci.nih.gov/fact/3_13.ht

14 NHS Direct (2005) How do I know I have reached the menopause if I am using the contraceptive pill?

15 Northrup, C (2001) The wisdom of menopause, London: Judy Piatkus

16 Stoppard, M (2005) You'll love the vintage years, retrieved www.mirror.co.uk/sexandhealth/miriam/tm_column_html

17 Trussell, L et al (1990) Contraceptive failure in the US. An update. Studies in Family Planning, 21(1), pp 51-54

18 Weber, G (1990) A season for sex. Healthsharing Fall/Winter pp18-22

19 Yee LA and Sunquist KJ (2003) Older women's sexuality. Medical Journal of Australia, 178 pp 640-642

20 Harris, G (2004) Pfizer gives up testing Viagra on women. Source: New York Times. Retrieved from

www.sensualism.com/sex/viagra.html

This article has been reproduced by kind permission of Women's Health London. It has been edited by Women's Health Concern and reviewed by one of our Medical Advisory Panel. Review date: November 2006.

© Women's Health Concern. Charity No. 279651

Email advice: advice[at]womens-health-concern.org (NB: please type @ instead of [at] in your email)

Website: www.womens-health-concern.org

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