The Ultimate Guide to Sex after Fifty

If you’re experiencing pain with sex or avoiding sex because of pain, you need a medical diagnosis. That’s sometimes tough, because most doctors don’t know enough about sexual pain to diagnose it. If your doctor advises you, “Just use more lubricant,” or assumes it’s all in your head, or prescribes a medication that might or might not be right for your problem, ask for a pelvic/sexual pain specialist who knows how to assess what kind of pain you’re having and its cause. This assessment needs to include the pelvic floor muscles and nerves—and that takes a specialist.

Sexual pain is complicated. It can be caused by a number of medical issues, and each one is treated differently. Until you and your doctor understand why you’re having pain, you can’t treat it effectively.

SEX SHOULDN’T HURT ³⁶

By Melanie Davis, PhD

Pain is the body’s way of asking you to put on the brakes and ask questions. Some causes of sexual pain can be easily remedied: Do you need more lubrication? A different position? A slower pace? Others require sex therapy or medical assessment and treatment. If pain occurs regularly, get a pelvic exam to get a medical opinion on possible causes. If the pain is chronic, you may need to redefine sex so it features physical sensations you still find pleasurable.

If it’s been a long time since you had sex, you may have jumped into intercourse before your body was ready. Try more pre-penetrative sex play to allow yourself and your partner to get very physically aroused. Also, your vagina may be out of shape due to lack of attention. The muscles, tissues, and blood vessels in your vagina need exercise, and without it, the muscles get weak and inflexible, and lubrication, which may already be decreased due to menopause, flows even less.

Schedule a pelvic exam and speak openly about what you were doing when you felt pain. Some reasons for female sexual pain requiring medical attention include muscles that clamp shut involuntarily, yeast infections, skin conditions, and sexually transmitted infections. Internal conditions like endometriosis (scar tissue), fibroids (benign tumors), and cysts can cause pain with penetration.

If there is no medical condition needing treatment, try some self-pleasuring and long warm-up time to get your body ready for sex. It may help to let your partner watch you masturbate to learn how to touch you without causing pain.

—Melanie Davis, PhD, AASECT Certified Sexuality Educator and consultant, co-president of the Sexuality and Aging Consortium at Widener University.

• What kind of pain is it? Burning, shooting, throbbing, tearing, itching, stabbing, stinging, cramping, numbness, tightness?

• Where do you feel it? Certain parts of the vulva? Clitoris? Vaginal opening? Deep in the vagina? Bladder? Pelvis? Abdomen?

• When does it hurt? All the time? When wearing underwear? Just when touched? During intercourse/penetration?

To prepare for your appointment, I recommend filling out the questionnaire in chapter 5 of Healing Painful Sex: A Woman’s Guide to Confronting, Diagnosing, and Treating Sexual Pain³⁸ by Deborah Coady, MD, a gynecologist and pelvic/vulvar pain specialist, and Nancy Fish, MSW, MPH. This questionnaire helps you pin down the answers to the topics above. There is also a list of fourteen descriptions of symptoms for you to match with yours.

Your clinician will do a physical examination. Part of that will be finding out exactly where the pain is using the Q-tip test: gently touching different parts of the vulva and vaginal opening with a moistened cotton swab. When you feel pain, you’ll tell the clinician the severity of the pain on a scale of one to ten. This doesn’t sound pleasant, but the clinician will be slow and gentle, and it’s important for a good diagnosis.³⁹ Your exam may include cultures and blood tests, because pain may be caused by an infection or skin disorder. Assessing levels of estrogen, progesterone, and testosterone may also be helpful. ⁴⁰

Vaginal atrophy: the lining of the vagina gets thinner and lubrication diminishes due to lower estrogen levels after menopause. The vagina narrows, shortens, and becomes less elastic. This results in dryness, irritation, and vulnerability to vaginal infection (atrophic vaginitis) and urinary tract infections.

High-tone pelvic-floor dysfunction: the pelvic-floor muscles that support the vagina, bladder, and rectum become tense and cannot relax and stretch enough to allow penetration.

Vaginismus: involuntary tightening of the outer third of the vagina when penetration is attempted, making intercourse difficult or impossible.

Vulvodynia: burning, stinging, raw pain, which may be diffuse or localized to the vulva and vagina. The National Vulvodynia Association offers free, helpful online patient education, “Everything You Need to Know about Vulvodynia” at www.learnpatient.nva.org.

Provoked vestibulodynia/vulvar vestibulitis: a type of vulvodynia characterized by burning pain at the vaginal entrance with touching, penetrative sex, or pressure, even from tight clothing.

Interstitial cystitis: inflammation of the bladder’s lining, which causes urinary urgency, frequency, and pain.

Bacterial vaginosis: a form of vaginal infection characterized by a thin odorous discharge due to an out-of-balance shift in the vaginal ecosystem.

Pelvic pain (can affect women or men): Many possible causes include adhesions, scarring, interstitial cystitis, and endometriosis.

This is just a partial list of conditions that can cause sexual pain. Treatments differ depending on the diagnosis and the cause, so there’s no way I can offer a magic solution here. Your pursuit of relief may take you through a frustrating journey from doctor to doctor—one Harvard study found that 60 percent of women who sought treatment for vulvar pain saw three or more doctors, many of whom could not provide a diagnosis.⁴² I must point out that the women in this study were age eighteen to sixty-four—can you imagine the results if they all had been over fifty?

Your best bet is to get an appointment with a sexual pain specialist, who will likely also refer you to a pelvic floor physical therapist.

“Too often I have had patients with pelvic floor dysfunction come to my office and say they have been to ten different doctors and healthcare providers and their symptoms have not improved, or have worsened,” says Amy Stein, MPT, author of Heal Pelvic Pain. “Their medical professionals do not assess—or know how to assess—the pelvic floor muscles and nerves.”

Consult a pelvic floor physical therapist who has specialized post-graduate training in diagnosing and treating pelvic pain (not a regular PT who has minimal training in this specialty). Among other assessments, pelvic floor therapists do an internal pelvic evaluation, assessing the three muscular layers, how well they both tighten and release, and where pain is felt.⁴³ Your PFPT will use a variety of techniques to treat your problem and rehabilitate your pelvic floor muscles and will also teach you a regimen to follow at home.

AVOID THESE IRRITANTS ⁴⁴

Many common products and activities irritate the vulva and vagina. If you have vulvar irritation or pain, The National Vulvodynia Association, www.nva.org, suggests that you:

• Wear all-white cotton underwear and loose-fitting pants or skirts.

• Avoid pantyhose.

• Remove wet bathing suits and exercise clothing promptly.

• Use dermatologically-approved detergent such as Purex or Clear.

• Double-rinse underwear and other clothing that touches the vulva.

• Do not use fabric softener on undergarments.

• Use soft, white, unscented toilet paper.

• Avoid getting shampoo on the vulvar area.

• Do not use bubble bath, feminine hygiene products, or perfumed creams or soaps.

• Wash the vulva with cool to lukewarm water only.

• Urinate before the bladder is full and rinse the vulva with water afterward.

• Use a water-based lubricant for sex that does not contain propylene glycol.

• Avoid bicycle riding and other exercises that put direct pressure on the vulva or create friction in the vulvar area.

• Avoid highly chlorinated pools and hot tubs.

I am a seventy-four-year-old man with a strong sex drive. My wife can no longer have intercourse due to pain when I penetrate. I have always wanted to give pleasure, not pain, so it does not work for either of us. I give her oral sex at least weekly and she has wonderful orgasms that not only satisfy her but turn me on too.

It takes me much longer to reach orgasm now than it took when I was younger, so she is not able to get me off either manually or with oral sex. She tries to reciprocate but it does not work, as it takes me too long and I don’t get aroused enough. As a result I masturbate two or three times a week while reading erotica or watching porn. We are monogamous and care deeply for one another. I sometimes feel a bit guilty about my sexual habits but seem to need them to control my strong sex drive. I have had a very active sex life since puberty.

I have not tried using sex toys and maybe it is time to try that. My wife has consulted a specialist but had no good results from the effort. She is working on other health priorities currently so I do not expect a change there.

A sexual problem at our age is rarely just one problem. I am grateful to the reader above for illustrating that point. She has too much pain for intercourse. She can have orgasms through oral sex, but because of his age-related, slow arousal and lessened sensation, he can’t have orgasms when she tries to reciprocate.

Reader, there’s absolutely no need for you to feel guilt or embarrassment if masturbation with porn or erotica is the best way for you to reach orgasm. Instead of seeing your strong sex drive as a problem that should be controlled, I’d like you to celebrate that drive and your orgasms—which are strongly beneficial to your health.

You’re not doing anything wrong. In fact, you’re honoring your intimacy with your wife with the ways you’re working through your challenges and keeping your sex life intact. And yes, a good sex toy, such as a vibrating sleeve or the Pulse—which works even when you’re not hard!—will hasten your orgasms. Your wife might enjoy watching you use your sex toy and maybe stimulating you while you use it—she clearly wants to give you pleasure.

A very valuable guideline is to define sexuality as mutual pleasure rather than intercourse. Too many couples get into the pattern of “intercourse or nothing.” Defining sex as intercourse is an extremely risky, self-defeating approach because ultimately you will have ignored the all-important mind-body element of sexuality.

—Michael E. Metz and Barry W. McCarthy in Enduring Desire: Your Guide to Lifelong Intimacy

When one of you has sexual pain, it affects your whole relationship, both in and out of bed. The National Vulvodynia Association suggests that you look at these issues:⁴⁵

1. How satisfied were both of you with your sexual relationship before the sexual pain developed? Were there conflicts that you still need to resolve? How has sexual pain changed your sex life? How do these changes make you and your partner feel?

2. Teach your partner which areas of your body, sexual activities, and positions are painful and which are enjoyable. Ask which body parts are especially pleasurable to your partner, too.

3. Plan ahead for how you will deal with pain flares. If you agree on a plan for those times, such as cuddling only, you’ll avoid feelings of rejection and prevent misunderstandings.

4. Which nonsexual gestures of intimacy make each of you feel loved? Communicate this to each other, and make a point of doing at least one of these each day.

5. Redefine sex and intimacy to mean any sexual activity that gives you and your partner pleasure without pain, whether or not it includes penetrative sex. Be open-minded about new sexual practices that you may find exciting.

6. For help redefining your sexual relationship and dealing with all the other issues, see a sex therapist or couples counselor with experience dealing with sexual intimacy issues related to chronic pain.

I am left with an awful feeling of inadequacy in the bedroom. It feels as if my sexuality just dropped off the map. My husband tries to be sympathetic. He tells me his performance is not what it used to be either, but I know he still can perform and does still enjoy sex. This has changed our whole relationship and how we relate to each other. We have become roommates instead of intimate partners.

At fifty-six, I’d been without a partner for eleven years. I’d assumed that I’d be alone for the rest of my life. Out of the blue, I met an amazing man a month ago. We have fallen madly, deeply in love. Physical contact is so exciting and joyful, but I’ve discovered that vaginal penetration is very painful. Use it or lose it, I guess. My new partner and I are open and creative about sex and talking about sexuality. We’ve both been through long marriages destroyed by years of silence around sexual dysfunction. We won’t let that happen here: we have a connection so rare that is it worth almost any effort. I’ll be consulting a vulvo/vaginal pain specialist ASAP.

You read in chapter 4, Sex with Yourself and Toys, the importance of keeping yourself sexually healthy through unpartnered times with regular self-pleasuring, including penetration. If you let sex go at our age, it’s harder to get it back once you’re in a relationship. It’s important “maintenance” to keep the blood flow going to our genitals and keep the pelvic-floor muscles in good working order—whether or not we’re having partnered sex or planning to again.

After menopause, if we don’t have regular penetrative sex (whether with penis, sex toy, dilator/wand, or fingers), the muscles at the vaginal opening can lose their ability to fully relax (known as high-tone pelvic-floor dysfunction), and they stay in a clamped position where penetration is painful or impossible.

If your goal is to accommodate a penis, Ellen Barnard, co-owner of A Woman’s Touch, suggests these steps for teaching your pelvic-floor muscles how to relax:⁴⁶

1. Get fully aroused first.

2. Using plenty of lubricant, insert a slim penetrative sex toy that is slender enough not to cause pain.

3. Take several deep belly breaths, concentrating on feeling your vaginal opening relax with each long exhalation.

4. If there’s no pain, start to gently insert a finger alongside the toy as you breathe deeply. You can substitute a tapered toy for the toy-plus-finger.

5. Once you feel the opening relax, slip your finger or tapered toy in a little more.

I’m a post-op transwoman. I had been having problems dilating, and the Gyno from Hell (now my ex-doctor) suggested instead of the dilator, I should try the real thing. Oh sure, I thought, I’ll just call Dial-a-Stud.

Turns out I went to dinner with a guy I knew, and we went back to his place. He was seventy-one. I don’t know if he took a blue pill, but he was ready. He was of the mindset that girls should go down on guys but not the other way around. Before I knew it, he was on top of me trying to gain entrance. He didn’t even put on a condom.

The sex was painful and he could not get all the way in. I stopped him and saw I was bleeding. He ran for a towel so I wouldn’t get his bed bloody. He then went out to the living room and let me take care of myself.

The next day I called my regular doctor (not Gyno from Hell). She saw me and said that I had a condition called vaginal stenosis. A request was put in for an outside specialist, and I am waiting to hear about that.

The most annoying side effect of my prostatectomy is that I have pain whenever I orgasm. It’s a deep aching pain—primarily on my left side and below the base of the penis. I’ve discussed this problem with urologists and urology nurses, and most either scratch their heads or shrug their shoulders. One urology nurse laughed at me. The pain is more pronounced after intercourse versus masturbation. This has put a serious crimp in any sexual activity and enjoyment.

When a man experiences sexual pain, he often doesn’t report it. When he does, his problem may not be taken seriously or it may be misdiagnosed. For these reasons, it’s hard to estimate how common male sexual pain is, although a 2008 study of over four thousand men in Australia suggested that 5 percent of men suffer from pain associated with sexual intercourse.⁴⁷

Other studies have found that men with prostate cancer who have a radical prostatectomy may experience painful orgasm,⁴⁸ although doctors do not warn patients about this and are often not knowledgeable about it.

Men may experience genital or pelvic pain in the penis, perineum, anus, urethra, testicles, lower abdomen, or tail-bone. There are many possible causes of male sexual pain, including abnormalities of the pelvic (pudendal) nerves,⁴⁹ yeast or urethritis, prostatitis, bladder infection, sexually transmitted infections, skin conditions, side effects of surgery, nerve damage, adhesions, scarring, and Peyronie’s disease ⁵⁰—and that’s not a complete list. As with female sexual pain, only an accurate diagnosis can ensure effective treatment, so it’s important to get evaluated by a specialist.

Fortunately, the man who wrote me in the quote above kept persisting in his quest for relief, and he found it. Here’s his update:

I’ve discovered that pelvic floor therapy works for men. I’ve seen my pain with orgasm diminish by 50 percent after three sessions. It’s also helping with my occasional stress incontinence. Because of my prostatectomy and earlier surgeries, my abdomen was full of adhesions and scar tissue.

I found a pelvic floor physical therapist with specialized training. The exam was both external (abdomen, groin, upper thighs) and internal (rectal and internal pelvic floor assessment). She also used biofeedback to assess my ability to relax the pelvic floor and ultrasound therapy.

The therapy sessions and home exercises have helped to start breaking down some of these adhesions and scar tissue. It’s a shame that urologists don’t consider or prescribe this therapy more often for men, especially prostate cancer survivors. I also wish I had known about the benefits—physiological and sexual—of prostate massage and practiced it before my cancer diagnosis.

This chapter is just the first stepping stone for getting information and treatment for sexual pain. Fortunately, several books and websites are available now to help you, and many of these contain referrals to finding a specialist who can help you.

Once you have a diagnosis and a practitioner, there are helpful, reliable websites that can add to your knowledge. See also the books and websites in our Recommended Resources in the back of the book.

One superb resource for women is the Vaginal Renewal™ program from A Woman’s Touch (www.a-womans-touch.com/documents/VR%20booklet.pdf). This comprehensive, easy-to-understand, self-help program was created to help menopausal and postmenopausal women who were experiencing discomfort or pain during penetration. I recommend it enthusiastically.

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