The Ultimate Guide to Sex after Fifty

About half of all sexually active men and women aged fifty-seven to eighty-five in the United States report at least one bothersome sexual problem; one third report at least two. Yet doctors rarely address sexual concerns in older adults, particularly in women.²⁰

Getting older isn’t in itself the problem—it’s the array of medical conditions and treatments that wallop our sexuality. Chronic pain, movement limitations, medications, surgeries, reduced blood flow, fatigue—all these and more can leave our sexuality behind, physically and emotionally.

In my ideal world, we’d say to our doctor, “This [insert medical issue] is causing [insert sexual limitation symptom]. Let’s fix it, because my sexuality is a vital part of my quality of life.”

In reality, though, when we need medical help for sexual problems at our age, we encounter an array of obstacles. The first and most obvious is that the doctor doesn’t ask how we’re doing sexually and we don’t bring up the subject. We’re too embarrassed, or we don’t think a doctor can help us, or our medical appointments are too rushed to let us edge our way gingerly into a sexual question. If the doctor doesn’t bring up sexuality, the topic usually stays under the covers.

A survey of 1,154 gynecologists revealed that only 40 percent ask their women patients whether they are experiencing sexual problems and only 28.5 percent routinely ask about their sexual pleasure²²—and that’s across all ages. I’d make an educated guess that the numbers are much lower when the patient is our age. Even more cringe-worthy: “A quarter of ob/gyns reported they had expressed disapproval of patients’ sexual practices.”²³ Oh, great. How will that encourage us to bring up the subject? But bring it up, we must. As sex therapist Marty Klein, PhD, says, “Let the docs deal with their discomfort. They’re getting paid, and it’ll benefit their personal lives.”²⁴

If you’re a doctor reading this book and wondering how to bring up the subject of sex with your older patients, here’s a question guaranteed to get results: “How has sex changed for you lately?”

A doctor who is considerably younger may not view us as sexual beings and is likely to assume that we don’t have a sex life, or care about it. The doctor won’t think to ask us about sex, concentrating on helping us treat our ailments. It’s up to us to start the conversation.

We can overcome our own reluctance by preparing ahead what we want to say. Writing down our questions is a good strategy. Then we need to assert ourselves. When another issue is the reason for the appointment, a good plan is to say at the beginning, “I have something else I want to discuss with you. Let’s leave time for that.” Now you can’t back out.

We must commit to bringing up our sexual issues assertively and unapologetically. Only this way can we help ourselves, help our doctors know what we need (and want!), and—ultimately—help our generation and those that follow.

Even then we may run into what seems to be a dead end: our doctor may not know how to help us with a sexual issue. Again, it’s in our court. Please practice this statement:

When I first began to experience ED, I assumed it was a psychological etiology and did all the “right things” that I would recommend to a client—I am a sex therapist after all. When that didn’t help, in a flash of awareness, I realized that it was the new medications I was taking for blood pressure and Type II diabetes that were causing the problem.

For a while, just not taking the meds on the day I expected intercourse helped. But eventually it wasn’t enough. So I visited a urologist. He just wrote a script for Levitra and assured me that would suffice. The Levitra didn’t work, so he next prescribed Edex, the penile injection. That did help, but it is expensive and the shelf-life is short.

That exhausted his knowledge. He didn’t know about vacuum therapy. He was shocked when I asked him about penile implants: “I’ll have to find out more about that and get back to you.” He knew nothing about psychological issues.

He had no idea that “older” people still had sex. In fact, he was surprised that I even wanted sex. I’ve had similar experiences now with a second urologist. But equally shocking, several of my women clients have reported similar lack of knowledge in their gynecologists.

I’m a doctor’s daughter and a doctor’s sister, and doctors have literally saved my life. I believe that most doctors are doing their best to help their patients heal what ails them and enjoy the best quality of life. They’re well educated, they are constantly updating their learning as the world of medicine changes, and they care about their patients.

However, the lack of sexuality education in medical training is appalling—and little or none of it specifically addresses sex and aging.

That’s where the problem starts, but we can make sure that the story doesn’t end there. We need to talk out loud about our sexual needs and problems that might have a medical solution, and not go away defeated. We can’t let embarrassment stop us from describing vaginal pain or erectile problems, even if our doctor looks like he’s barely shaving.

We also have to take responsibility for reporting to our doctors when we’re having trouble with function or libido, because sexual problems can be the first warning sign of a serious underlying illness that can and needs to be treated—for example: diabetes, heart disease, an infection, urogenital tract conditions, and cancer.²⁵ Other health conditions that cause sexual problems are high blood pressure, underactive or overactive thyroid, lung disease, depression, kidney disease, chronic alcoholism, multiple sclerosis, atherosclerosis, and more.²⁶

The point is this: If there’s any change in your libido, arousal, or sexual functioning, please consult your doctor.

Medications themselves may cause sexual problems. Most of us are taking medications regularly these days—people over sixty are likely to be on three different meds.²⁷ These are among the drugs that can have sexual side effects: ²⁸

Cholesterol-lowering drugs: Statins and fibrates prescribed to treat high cholesterol can also affect the production of sex hormones such as testosterone and estrogen, resulting in reduced arousal, erectile dysfunction, and difficulty achieving orgasm.

Blood pressure medications: Many blood pressure drugs can have sexual side effects. Diuretics can affect the flow of blood to the genitals and cause erectile dysfunction, female arousal problems, and orgasm difficulties. Beta blockers can affect testosterone levels and the nerve impulses associated with arousal.

Antidepressants: Antidepressants can cause decreased libido in any gender, erectile dysfunction and difficulties ejaculating in male bodies, and difficulties in arousal and orgasm for female bodies.

Antihistamines: Drugs used to treat allergies, including over the counter drugs, can cause vaginal dryness and erectile dysfunction.

Tranquilizers: Drugs used to treat anxiety can reduce libido and cause erectile dysfunction and female arousal difficulties.

Antifungals: Drugs used to treat fungal infections can cause erectile dysfunction.

Anti-ulcer drugs: Drugs used to treat acid reflux, heartburn, and ulcers can cause low libido and erectile dysfunction.

Heart medications: ACE inhibitors, nitrates, beta blockers, and calcium-channel blockers can affect erectile function, arousal, and libido. (For more, see chapter 11, Heart, Brain, Joints, and Sex.)

Never just stop the medication that is causing the unwanted sexual side effect. You can worsen the original medical condition that warranted this medication. “Do not stop taking any prescribed medicine without your doctor’s advice,” advises pharmacist Paul Roberts. “If you suspect your medication is interfering with your sex life, it’s time to have a conversation with your doctor. Often lowering the dose may be possible, and the side effects will lessen. More likely is your provider can change you to something else that won’t have that side effect. Rarely do you just have to live with it.”

Ask your doctor or pharmacist about the best time to take your medications so that they affect sexual response or sexual function less. “Sometimes timing can make all the difference in preventing side effects from interfering with your sex life or daily life,” says Roberts.

Level with your doctor about the sexual side effects and that you value your sex life. Be clear and determined, and not confrontational. Assume that your doctor is willing and able to assist you and just needs to understand what the problem is and how important it is to you.

HERBS FOR SEXUAL ENHANCEMENT

by Paul Roberts, RPh, MS, Certified Geriatric Pharmacist and nutritionist

Some herbs are reputed to enhance sexual libido and function. Do they work? Herbs for sexual function are rarely used alone—they’re found with several others in combination. Therefore it’s difficult to determine which individual ones work, and adequate studies for safety are generally lacking. Fortunately herbs have generally mild effects and a good safety record overall, compared to prescription medications.

Be sure to tell your doctor what herbs you’re taking or considering taking, because they may interact with another medication you’re taking or aggravate a condition you have. Avoid these if you have hormone dependent cancers or other hormone-linked medical conditions.

These herbs are commonly used for sexual function:

Tribulus (Tribulus terrestris) “Puncture Vine”

Uses: to treat impotence and infertility. Tribulus is widely used in combination with other herbs for sexual dysfunction in men.

Contraindications: Do not use if you are diabetic (it may lower blood glucose levels), take lithium, or have benign prostate enlargement or prostate cancer. Tribulus may interact with some heart and blood pressure medicines, such as beta-blockers, calcium channel blockers, digoxin, and diuretics. Avoid this herb for sexual dysfunction in women, as it’s likely to aggravate the condition.

Conclusion: Although there is little scientific evidence that it works, Tribulus is possibly effective for men and may be worth a trial for up to 8 weeks if you do not have any of the contraindications.

Korean ginseng (Panax ginseng)

Uses: to improve erectile dysfunction, libido, sexual arousal in women, and orgasmic function.

Contraindications: Avoid if you are taking blood thinners or have autoimmune disease. Avoid if you have schizophrenia unless prescribed by your doctor.

Cautions: Use only under medical supervision if you are taking antidepressants, antipsychotics or are diabetic. It may cause insomnia and increase the effect of caffeine.

Conclusion: Adverse effects rarely reported in doses of 500 mg to 2,000 mg for four weeks to six months. Found to significantly improve sexual function over four to twelve weeks. Libido, orgasmic function, and sexual satisfaction have been shown improved over eight weeks. Ginseng can be considered for improving ED in men and enhancing sexual arousal in women if you do not have any of the contraindications or cautions.

Maca (Lepedium meyenii)

Uses: for impotence, as an aphrodisiac, and to relieve stress. Maca root in dried, processed form has been consumed by Peruvians regularly for several thousand years.

Cautions: Although traditionally used to establish female hormonal balance, no studies have been done in women.

Conclusion: Maca is possibly effective for increasing libido and increasing sperm amount at 1.5 to 3 grams daily of the dried powdered root. More studies are needed to verify other uses. Likely safe (in the dried form) for short term, up to three to four months. Due to widespread use and safety, in spite of lack of studies, combinations with Maca may be worth a trial in healthy individuals.

Chrysin “Passion Flower”

Uses: for impotence and increasing testosterone. It is purported to inhibit the conversion of testosterone into estrogen, however studies that show this are lacking.

Contraindications: Avoid with prescription aromatase inhibitors (Femara®, Arimidex®, Aromasin®) because it may increase the drug’s effect. May interfere with anticoagulant, platelet treatments or cause low blood pressure. Avoid if you are immunosuppressed or immunocompromised.

Cautions: May increase levels of some drugs cleared by the liver enzyme “Cyp1A2” including caffeine. Ask your pharmacist or doctor if this could affect any of your prescriptions.

Conclusion: Avoid this herb until more is known.

Wild Yam (Dioscorea villosa)

Uses: to increase energy and libido in women.

Cautions: Claims that Wild Yam is a natural progesterone or has progesterone effects are not supported by studies.

Conclusion: No reports were found of adverse effects when used in appropriate doses for short term. However, Wild Yam is not converted to hormones in the body as is commonly believed, only in the laboratory. Avoid this product.

Damiana (Turera diffusa)

Uses: to prevent and treat sexual dysfunction and as an aphrodisiac.

Cautions: The research studied Damiana in combination with other ingredients, however studies of the herb alone are lacking.

Conclusion: May be safe in appropriate doses for short term, but possibly avoid this herb until more is known.

[For a longer version, see www.NakedAtOurAge.com, with “herbs” in the search box.]

You and your medical provider need to decide together whether hormone replacement therapy is the right option for you, and, if so, in what form. So many factors go into this decision that I can’t possibly give you a simple answer. You need to decide in the context of your symptoms, your medical conditions and risk factors, concerns based on your family history, and more. What hormones are you lacking, and to what degree? How is this affecting you? What are the pros and cons in your situation?

Hormone replacement therapy for women may be estrogen only or a combination of estrogen and progestin. Often started at perimenopause to alleviate symptoms of hot flashes and vaginal dryness, HRT can remain helpful after menopause to combat bone loss and vaginal thinning and dryness.

However, research studies starting with the Women’s Health Initiative in 2002 have called into question the benefits versus the risks from HRT. Combined estrogen and progestin and estrogen-only therapy may increase risk of stroke, deep vein thrombosis, gallbladder disease, and urinary incontinence. It does not protect against heart disease as once thought. Estrogen-only therapy increases the risk of endome-trial cancer. Combined estrogen and progestin increases the risk of breast cancer. ²⁹

In a 2013 update, researchers reaffirmed that hormone therapy can be beneficial in short-term use to manage menopausal symptoms, but “there are no reliable data on the risks or benefits of long-term hormone therapy use for the prevention of chronic diseases.”³⁰ At the time of this writing, researchers continue to investigate the risks and benefits, and whether the risks relate to duration, age at which the therapy was started, how it was given, and other factors.

Meanwhile, your doctor will work with you to determine whether the benefits of HRT outweigh the risks in your particular case, and if so, what form should you take? Hormone therapy can be systemic (released into the bloodstream and used throughout the body) or local, such as the vaginal ring that releases small doses of estrogen directly into the vaginal tissues to increase lubrication, thickness, and elasticity,³¹ or a dab of testosterone rubbed onto the clitoris.³²

If you prefer to use plant products or bioidentical hormones, please consult your doctor—don’t just proceed on your own. These can also carry risks and may have additional safety issues.³³ Whatever you decide to do, take the lowest dose that helps and for the shortest time necessary, and get checked out every six months.³⁴

Men experience lowered testosterone with aging and with some medical conditions and treatments. Low testosterone can lead to erectile dysfunction and a lower sex drive. If your doctor determines that testosterone replacement therapy is right for you, there are many options: injections, patch, gel, tablets, subcutaneous implant, and more. Caution: Have a thorough prostate cancer screening first. Men with prostate cancer or breast cancer should not take testosterone.³⁵

In The Whole Lesbian Sex Book: A Passionate Guide for All of Us, author Felice Newman recommends that you consider these questions when choosing a healthcare professional:

If you’re looking for a new health professional, Newman recommends checking the listings at www.glma.org/, the website of GLMA: Health Professionals Advancing LGBT Equality (previously known as the Gay & Lesbian Medical Association), the largest and oldest association of lesbian, gay, bisexual, and transgender healthcare professionals.

What if our doctor’s attitude is demeaning and getting in the way of us getting the right treatment? Especially when we’re seeking help for a sexual concern, when we might be embarrassed to begin with, the wrong reaction from our doc can mean the difference between getting the help we need—and not.

It’s time to get a new physician if your doctor does any of these consistently:

When sex goes awry, it affects your sense of who you are as a person and, if you’re partnered, as a couple. Partnered, single and dating, or solo: you’ll need communication tools and strategies to remain sensual—especially when not everything is working.

Even when your problems are medical and in no way “just in your head,” counseling can be a useful adjunct to medical treatment. If your medical condition is limiting you outside the bedroom as well as inside, a counselor can help you cope with the limitations. You can work toward a new sense of yourself.

For these and many other reasons, please give yourself the chance to find out how a therapist or counselor can give you a new way of seeing your life moving forward, whatever challenges you’ve been given.