We found this chapter on sex during and after menopause to be particularly challenging to write. It’s not because we have little to say. On the contrary, what we want to speak about here is of utmost importance to every woman, regardless of her age, ethnicity, or life experiences. This is so important, in fact, that we struggled to find words that will grab your attention and open your mind to our message. It isn’t an easy task, as we are fighting hundreds of years of myth and misunderstanding.
What we are referring to is the universally accepted but completely unfounded belief that women become less sexual as they age. It’s true that at one time in human evolution, women didn’t live much beyond menopause, if they managed to survive that long. Today, however, a majority of women not only outlast “the change,” they thrive in their postmenopausal years.
Like other life transitions, menopause can impact a woman’s libido. But this hardly means that she’s no longer capable of being sexy or enjoying her sexuality. Still, our society insists on embracing the notion that women are sexual only before menopause. This myth is so pervasive that it has remained largely unchallenged by both men and women. The reality, however, is far different.
Let’s begin with an understanding of what perimenopause and menopause really are. The World Health Organization has defined menopause as the permanent cessation of menstruation resulting from the loss of ovarian estrogen production. Perimenopause is the period of time starting with the onset of the first signs of approaching menopause (hot flashes, vaginal dryness, memory changes, mood swings, changes in the duration or interval of menstrual cycles) until 1 year after the last menstrual period.
A woman’s menstrual cycle is regulated by a complex communication system between her brain and her ovaries. The brain—specifically the pituitary gland, under control of the hypothalamus—secretes what’s known as follicle-stimulating hormone (FSH), which signals the ovaries to produce a mature follicle. In turn, this follicle secretes estrogen that then alerts the pituitary gland to stop producing FSH. This is called a feedback loop.
As a woman ages, her follicles become more resistant to stimulation from FSH. The pituitary secretes increasing amounts of FSH to drive the ovaries to produce a mature follicle. Eventually, they do, but because of the high levels of FSH, the follicle will “overshoot” and produce an abundance of estrogen. This creates large swings in the body’s estrogen level. It is these markedly fluctuating estrogen levels that are responsible for perimenopausal symptoms. Eventually, despite ever-increasing FSH, the aging ovaries cannot respond to make a mature follicle, and the ovaries’ estrogen production ceases. It is this loss of estrogen that brings on menopause and its associated symptoms.
As we explained in chapter 6, a woman’s sexual response is greatly influenced by estrogen. As her estrogen levels fluctuate wildly in perimenopause, so too can her sexual response. And, as her estrogen drops to low levels after menopause, her sex drive and her sexual arousal can suffer as well. The loss of estrogen can have two effects on a woman’s sex life: She may experience a decrease in libido, and even more profoundly, she may experience serious negative changes in the health of her vagina and her ability to become sexually aroused.
The labia, clitoris, and vagina all require estrogen for the maintenance of optimal sexual functioning. In addition, the blood vessels, muscles, and nerves of the urogenital tract are heavily dependent on estrogen. The overall effect of the lack of estrogen during perimenopause and menopause is decreased blood flow to the vagina and clitoris. This leads to decreased vaginal lubrication and decreased sensation during sexual arousal. Often, the strength and quantity of orgasms diminish. In addition, there is a profound thinning of the mucosa of the vagina, which, combined with decreased lubrication, can cause sex to be uncomfortable—or even severely painful.
In chapters 7 through 9, we explained how supplemental testosterone, along with other medications and herbs, can stimulate diminished sex drive. It would seem easy to treat a low sex drive that results from the estrogen loss after menopause with estrogen replacement. And, in fact, estrogen replacement has been an integral part of the health care of menopausal women for more than 60 years. Most physicians have been taught that women should have “adequate” estrogen from “puberty to the grave.”
However, recent large-scale studies such as the Women’s Health Initiative have called into question this long-held belief. Almost monthly, new studies report increased risks associated with estrogen replacement, including a greater likelihood of breast cancer, strokes, and heart attacks. Therefore, although we realize that estrogen replacement can help improve a waning libido, given the current uncertainty regarding the safety of this treatment, we cannot wholeheartedly endorse it at the present time.
As there are hundreds of books devoted to just this issue, we feel that addressing it is beyond the scope of our book. Therefore, we encourage you to have an in-depth conversation with your physician regarding the risks and benefits of, and alternatives to, estrogen replacement. We also suggest that you keep up-to-date on the current landscape of medical opinion by following the recommendations of respected and nonpharmaceutically affiliated medical organizations such as the North American Menopause Society (www.menopause.org) and the American College of Obstetricians and Gynecologists (www.acog.org).
Although we are ambivalent about recommending oral estrogen replacement, we are convinced that localized estrogen replacement for the vulva and vagina is an important treatment for the atrophic changes that accompany menopause due to lack of estrogen. We believe that localized estrogen replacement is safe, because if used correctly, it does not raise the blood levels of estrogen and, therefore, cannot increase the risk of breast cancer, strokes, and heart attacks.
There are several different methods of estrogen replacement: creams, vaginal tablets, and estrogen rings. All three work well, but each has its individual benefits.
The estrogen creams (Estrace and Premarin) tend to be a bit messy, but they can be rubbed directly into the vulva and on the clitoris and therefore more quickly improve the health of these organs. This is especially important at the entrance to the vagina, known as the vestibule. The vestibule is especially susceptible to atrophic changes that can make penetration painful.
The vaginal estrogen tablet (Vagifem) is easy to use and not messy. It comes with a little applicator that deposits the tablet deep into the vagina. (It reminds us of a Pez dispenser.) You typically do the treatments two times weekly.
The last option is the estrogen rings (Femring and Estring). The soft, flexible ring is placed into the vagina and stays there for up to 3 months. It steadily releases a small amount of estrogen to greatly improve vaginal health. If it’s positioned properly, a woman does not feel it in her vagina. The estrogen ring is good because of its ease of use. Slowly but surely, the vagina will once again become the warm, moist, inviting place that it once was.
In addition to localized estrogen replacement, we recommend vaginal lubricants until the vagina has regained its moisture and lubrication. There are dozens of products available, but we often recommend using either Slippery Stuff or Astroglide. Both are glycerin-free, water-based, odorless, tasteless, long-lasting, and latex-compatible.
From an emotional perspective, we like to think of menopause as an invitation. It is your body’s way of tempting you, perhaps in not such a subtle manner, to change and grow. It forces you to discard your old ways of understanding yourself, most obviously on a physical (and sexual) level. But in actuality, it also challenges you to grow spiritually, emotionally, and intellectually.
Those women who accept the invitation in all its forms seem to get more for themselves in the process. For them, menopause can be a rich adventure. The unexpected surprises and delights available at this time of life can help to balance the pain and loss that are also associated with growth. For these women, menopause can be a time of self-, and sexual, liberation.
Unfortunately, for most of us, change is a bad word—especially when the change is neither initiated by us nor in our control. We receive this invitation with reluctance and fear. Those who prefer to fight or ignore it will usually experience a sense of constriction in their lives. The constriction is the result of loss—losing pieces of the women they were—untempered by gain—the discovery of the women they can become. They tend to suffer more, because they struggle to hold on to what they can no longer have. Women whose lives contract in this way tend to experience their sexuality, and their libidos, as contracting right along with it.
But really, who can blame them? Our culture highlights the loss inherent in menopause. We need only look as far as our TV and movie screens to receive that message, loud and clear, on a daily basis. The career trajectories of Hollywood’s most popular movie stars provide poignant examples.
Those actors who epitomize masculine sexuality bring us back to the box office repeatedly over the years. Even as they show signs of aging, such as graying hair or changing muscle tone, they become only more enticing and distinguished. Our masculine idols seem to actually gain power and status as they mature.
For their female counterparts, however, a completely different scenario unfolds. Our love for them is much more fickle. A sexy actress can hold our attention until her youth begins to fade. Then we lose interest—and she is cast aside for a younger, more physically perfect specimen.
Although this may be the “truth” our culture perpetuates, we suggest opting for a different reality. It’s time for us to open our minds to a healthier, more realistic appraisal of what makes a woman valuable, and what sexuality during menopause and beyond can be. Losing the capacity to create new life is not synonymous with losing the capacity for rewarding sexual experience and a healthy sex drive. Louise was a casualty of just such caustic thinking patterns.
Louise was a vibrant, intelligent 70-year-old widow. She lost her husband to colon cancer 6 years before calling me (Dr. Brandon) to schedule an appointment. On the phone, she told me she was lonely, in spite of her many friends and busy calendar. She loved her work as the manager of an expanding medical practice. But, she explained, something just wasn’t feeling right.
Louise adapted quickly to the rhythm of therapy. She thoroughly enjoyed the self-exploration and growing connection between us. After several months in treatment, she arrived in my office looking grave and determined. “I have something very important to discuss,” she announced. “You might think I’m crazy, but I need to say it.”
My heart went out to Louise; she looked scared and uncomfortable. I listened quietly, though my mind was racing. What could she possibly be preparing to tell me?
Louise spoke with tears in her eyes. “I miss having a man in my life. But it’s more than that,” she confided. “I miss having sex.” Silence. The word sex loomed large in the air between us. Could it be the source of Louise’s shame and discomfort?
The answer to this question, I am so sorry to say, is yes. This lovely woman felt like a freak because she missed sex and wanted it back in her life. Louise believed that a widowed septuagenarian shouldn’t be thinking about such things, let alone desiring them for herself.
If it is a myth that women lose their sexuality with age, then what’s the reality? Research repeatedly demonstrates the same conclusion: Women’s sexual concerns do not increase as they transition through menopause and beyond. In fact, some women report a decline in sexual difficulties during this time.
The exception appears to be lubrication—women do report difficulty lubricating with increasing age. As we already discussed, this age-related sexual symptom is fairly easy to address.
Recent research indicates that for many women reporting sexual issues during menopause, poor body image may actually contribute more to their discomfort than hormonal changes. We believe that this is a pivotal message because, as we’ve discussed before, your expectations can have a huge impact on the reality you embrace. So, if you expect to lose your libido as you age, to find sex uncomfortable, and to view yourself as asexual, your chances of living that out increase substantially. Why not create a different, sexually satisfied, existence?
Interestingly, men also experience sexual struggles at midlife and beyond. They may also suffer significant age-related sexual dysfunction. To give you a few examples, men need more time and stimulation to become erect as they get older. Their erections are not as rigid. They need more time between erections than their younger counterparts. And potential health problems such as heart disease and diabetes can have more-intrusive effects on a man’s sexual performance than on a woman’s. So here’s the real irony: Despite our culture’s perceptions, men’s sexual prowess can be said to suffer more with age. The apparent decreases in a woman’s libido are more likely to be related to a decline in her partner’s health or his reduced interest rather than her own. Likewise, her partner’s sexual function is an important indicator of her level of sexual satisfaction.
So what about those women who report a diminished level of desire during or after menopause?
First, many of them have been struggling with low desire since before their perimenopausal transition. So low libido isn’t necessarily a new concern for them. In fact, it seems that some women speak about it at this time in their lives because they finally feel justified in doing so. Menopause may offer a more socially acceptable understanding of their decreased sexual interest, so they may feel less shame and self-criticism about it.
Second, menopause is a time of great emotional change. New self-definitions are created as outdated ones are left behind. We call it a menopausal transition because, from an emotional perspective, it involves a process of self-discovery that is usually several years in the making.
During this time, a woman is challenged to relearn herself in pivotal ways. For a while, she really doesn’t know who she is becoming. Her body is changing and in many ways unfamiliar. She hasn’t “lost control” of her body since pregnancy, and that was more than 2 decades ago. Sudden hot flashes, night sweats, and urinary urgency feel unwelcome and intrusive. Her family is changing, too. Her children are probably moving out of the house, and with them, her major life role as mother and caretaker.
For all of these reasons, the experience of making love can be particularly difficult. That’s because a woman must essentially find a way to share herself intimately without even knowing who she is yet. This can be frightening, and it can cause a woman to lose interest in sex.
Some women seem particularly traumatized by the changes going on in their bodies. As we discussed, the decline in estrogen can have profound effects on a woman’s sexual organs. Accepting the changes that result from decreased blood flow to the genitals isn’t easy. She may feel particularly demoralized by it, and it has a direct impact on her desire to make love. Sex simply reminds her of these changes. If she can’t accept her new body, she will have a difficult time sharing herself intimately and sexually.
If you are searching for your lost libido during menopause, the first step in reclaiming your desire is to shift your perspective and understanding of what’s happening to your body. Rather than focusing on the aspects of menopause that are sexually constricting, we invite you to see the other side of the coin.
Menopause does involve loss and forced change. And you are losing something that’s valuable and worth grieving for. We urge you not to ignore the grieving process—take the time your soul needs to say goodbye to that part of yourself. Letting go is a real milestone in the process. Respect yourself and your body enough to do it consciously. However, with all loss there is gain. Your sexuality is no exception to this rule. We extend to you the invitation to explore how menopause really can be a sexually liberating transition for you.
Let’s start with the most obvious facts. First, you are free from worrying about pregnancy. No longer do you have to concern yourself with birth control when making love, or anxiously wonder why your period is late. Your sexuality really can be all about pleasure now.
Second, remember that you are not alone. Think of the women you’ve known and loved who have moved through menopause while maintaining their sensuality. If you can’t identify any, then consider Lauren Hutton, Raquel Welch, and Sophia Loren.
Remember, too, that your partner is experiencing unwelcome sexual changes. He’s probably feeling self-conscious about his aging body. Together, the two of you can create a new, shared sexuality.
Use this transition to let go of outdated societal notions about what it means to be a woman. You are moving into a wiser, richer time of life. Let go of perfectionist standards of what makes a woman valuable in Western society. Is it really her thin thighs? Her ability to conceive babies? We think not.
Also use this transition to make your own rules. It’s not about society telling you what makes you worthwhile. Now is the time for you to decide this for yourself. Women who are postmenopausal make up about a third of the female population. Use the strength in your numbers to redefine what it means to be sexy. Allow your more assertive, more “masculine” energies to find their true voice. Discover what you want to do, rather than what you “should” do.
This work facilitates knowing yourself on a much deeper level than you may have in the past. You learn more about who you really are, under all the layers of your socially acceptable exterior. And your sexuality can be freed up along with you. This is where your deepest passion lies. If you go there, you are in for a sexual treat.
There is another gift for you embedded in this change. The loss of the physical allows you to spend more time and energy on what is really you, what is really important to and about you. Rather than giving birth, you can now focus on your own rebirth. Your sexual experience can reflect this. As your sexuality becomes less physically based, you make room for the emotional. Many women find this leads to much more meaningful and satisfying sexual relationships.
We’d like to note that some women simply need time to reclaim their sexual desire at menopause. Time allows them space to get to know themselves. Many women find this necessary before they are comfortable sharing themselves with someone else in as intimate a forum as making love.
If you are struggling with low libido during menopause, we encourage you to turn your focus to what many call the most powerful sex organ: your brain. Give yourself permission to rediscover your sexuality, just as you are discovering other aspects of yourself as well. Usually, this entails exploring new ways of being sexual alone with yourself, as well as with your partner.
Start by setting the conscious intention to relearn your sensuality and enjoy it in new ways. Focus on creating and receiving pleasure through your five senses, rather than your sex organs. After all, the root of the word sensual is “sense,” implying that your senses are necessary to the experience of sensuality.
There are always different ways for you to explore your sexuality through your senses. It really doesn’t matter what your past experience has been. Stop thinking of sex as having to involve orgasm and intercourse. We’ve discussed previously how sex can involve masturbation, mutual masturbation, oral sex, and vibrators. We now invite you to expand your sexual repertoire even more.
In approaching sensuality from the perspective of your senses, don’t think about sex as you may be accustomed to defining it. Your focus is on finding sensuality in sounds, smells, tastes, textures, and sights of typically nonsexual matter. For example, the sounds of waves can be a sensual experience for many, as can the “sound” of perfect silence early in the morning. Spend time at a record store searching for sensual music. Some people find classical music or opera stimulating; others like drumming or exotic, foreign selections. Many music stores now have ways for you to listen before you buy; so do Web sites that sell CDs. Take advantage of the opportunity to develop your sexuality in this creative fashion.
What about touch? Believe it or not, sensual touch doesn’t have to involve a human body. In fact, nature provides us with many alternatives on a daily basis. Running your fingers over fur, for example, can be a sensual experience. Or experiencing the tingling sensation of cool water on your inner elbows as you stand at the kitchen sink. Try it for yourself. Feel the sand against your body as you keep your grandchild company in her sandbox. Lie in lush, green grass and meditate on the experience of allowing sunshine to penetrate your skin. Feel it entering your body from your feet, the crown of your head, and all the places in between. Feel a breeze as a full-body sensation, rather than just on your face. Offer yourself tactile delights such as these in your efforts to find the new sexual you.
Find sensual delights for your eyes as well. Stare into a candle flame. Hold a piece of glass to the light and watch it sparkle. Stand under a tall tree and look toward the sky. Check in with your body to feel an even deeper experience of these visual sensations.
You probably already know what a sensual experience certain tastes can be. Chocolate, fruit, wine, and olives are good places to start. Let your taste buds lead you to new sensual delights.
And don’t leave out your nose—your sense of smell can trigger all kinds of sensual responses. Roses are an obvious erotic pleasure, as are perfumes and home-baked bread or cookies. These aromas fill our senses and envelop us. Notice this powerful effect the next time you smell something wonderful. Take a moment to scan your body, and you will find that your entire body reacts to a fragrance—not simply your nose.
As you can see, creativity and flexibility are key as you rediscover your sensuality. You can take these same qualities to your lover as well. Try out new patterns together—for example, vary the time of day that you typically make love. Again, be sure to focus on pleasurable interchanges rather than orgasm and intercourse. Spend time massaging each other’s hands and feet. Savor a piece of chocolate cake together. A decreased focus on physical activity can free up space for deeper, more emotionally powerful connections. Pat and Clarence certainly found this to be true.
Pat came to my (Dr. Brandon’s) office about 1 year after experiencing her first hot flash. She had never been to therapy before; she was trying it in an effort to avoid starting an antidepressant. Pat had mixed feelings about therapy. Although she didn’t necessarily want to take another medication every day, she didn’t think simply talking to someone would make much difference in her mood and quality of life.
When asked about her depression, Pat hesitantly spoke about feeling lonely in her life and in her marriage. In the previous few years, Pat’s husband, Clarence, rarely expressed any direct sexual interest in Pat. This was fine with her, she assured me, as she didn’t feel much like being sexual any longer. She had apparently been rejecting his advances for a while. “I’ve had my children,” she said. “No need for that any more.” I asked why not.
To begin with, Pat wasn’t happy with the changes going on in her body, sexually and otherwise. Her hair—including her pubic hair—was thinning. Her skin was less elastic and more translucent than in the past. Her vagina didn’t feel as tight as it used to. She believed that her genitals had developed an odor. The last few times she and Clarence had made love, she noticed that she hadn’t lubricated as much. She was painfully aware of having more cellulite and less muscle than when she was younger. Sometimes when she coughed or sneezed, she was afraid she’d lose control of her bladder. It all added up to Pat wanting a break from sex.
We talked about how bound to her body Pat’s perceptions of her sexuality were. Not only that, she held on to an image of what her body used to look and feel like as her sexual ideal. If she kept this up, sex probably would never be rewarding for her again. But there was an alternative. Would her sexuality become more interesting to her if she expanded her understanding of her sensuality? It seemed like a way to help Pat rediscover her sexuality while simultaneously working on her depression by engaging her more fully in her world.
I started Pat on homework of exploring sensual pleasure through her senses. She found painting with vibrant colors to be a particularly erotic experience. When focusing on the paint, Pat found herself transported by the vivid splashes of light across her canvas. Pat then learned to focus on the ways that pleasure manifested itself in her body—she described it as a “tingling, alive” sensation in her torso. Pat used her awareness of these sensations to facilitate similar reactions in her body at other times, such as in the bathtub or when walking in the sun. Before she knew it, she felt more alive and engaged with her surroundings and their impact on her body than ever in her life. She began to get interested in branching out and including Clarence in her rediscovery.
Pat built up the courage talk with Clarence about her discomforts with her changing body. She learned that he, too, disliked the way his body was changing. When Pat talked with her friends about how they were changing sexually, it became clear to her that she was not alone. Setting her own standards for her sensuality began to make more and more sense to her. Pat’s increased interest in bodily pleasures was met with much enthusiasm by Clarence. They found a new softness when relating together, even outside of the bedroom. Pat’s courage in breaking the mold of what it meant for her to be sexual was paying off.