Chapter 9
Maintaining Your Sex Life Through Menopause
In This Chapter
Understanding how your libido can cha-cha-cha when your hormones are doing the rumba
Getting the scoop on your partner’s libido
Warming up the sheets
Facing the challenges of fertility in your 40s
Bravo for life’s little ironies. You may discover that at about the same time your kids are moving on (and out), you finally have the leisure (and the cash) for those romantic weekends; your doctor gives you the green light to toss your contraception; your body is ready to make whoopie; but your sex organs are preparing for retirement. Or you may discover that your organs are still willing, but your hormones are not.
On the other hand, you may expect interest in and capacity for great sex to decline, only to discover that menopause is the best thing that ever happened to your sex life. Just don’t just assume that the dire predictions about loss of libido and dewy freshness giving way to disinterest and dryness are the rule for everyone. Lots of women find sex after menopause to be better than ever.
There’s no question, though, that sex changes after menopause — your hormonal shifts have repercussions for your private parts as well as your emotional parts. There’s also plenty of pesky cultural silliness to deal with — an awful lot of folks still hold to the idea that women of a certain age aren’t supposed to be sexy, or sexual. In this chapter we’ll talk about why you shouldn’t kiss your sex life goodbye just yet, why you still need to be careful about birth control (and why it may not be too late for a baby if that’s where your heart lies), and suggest some ways to keep the home fires burning as you approach and enter menopause.
Looking at Menopause and Your Libido
Menopause opens a new chapter in your life, so it’s no surprise that the sexual you changes as well. In many cases, the changes are for the better. Even though there’s never been a medical reason for you to abstain from sex during your period, most women and their partners refrain from sex for those days. Now that those menstrual periods have hit the road (or are at least packing for the journey), you have more opportunities for sex. And remember how you always seemed to get your period when you were on vacation, no matter how well you planned? Now you can play around until your heart’s content without checking and double-checking for those red circles on your calendar. The crankiness, cramps, and headaches that characterized much of your menstrual cycle now level out into a kinder and gentler expression of you.
Libido often declines with age. Most scientific studies have found that little change in sexual activity occurs between the ages of 45 and 55. But, between 55 and 65, sexual activity slows.
And, though women in their 60s may not engage in sex as often as they did in their younger years, no change occurs in the frequency of orgasm or the level of sexual enjoyment. So, you may not do it as often, but sex is just as satisfying. (An interesting note: Research shows that activity with sexual partners often slows down long before women discontinue masturbating.) Quality doesn’t have to decline just because quantity does!
Letting your feelings be your guide
When it comes down to it, no one knows your body better than you do, so pay attention to it. Because every woman experiences menopause a little differently, your medical advisor may not be familiar with what’s normal for you — and what seems different to you. Learn to trust yourself and communicate openly with your doctor.
This advice goes double for changes in your libido (desire to have sex). Many doctors ignore sexual issues when treating perimenopausal and menopausal women. So it’s important that you bring up the issue if your doctor doesn’t.
Here are some helpful hints for talking to your doctor:
Doctors have heard everything; don’t feel embarrassed about your questions or concerns. If you don’t feel comfortable discussing sex and sexuality with your doctor, find one who’s more engaging.
Raise your questions early in the appointment. Take a moment right after the “Hi, how are you doing today” part to raise the issue by saying something such as, “ . . . and there’s another problem that we need to solve before I leave today.” Waiting until you’re actually walking out the door to bring up a sensitive issue happens so often that doctors actually have a name for the phenomenon: “the doorknob moment.”
Keep a diary of any pain, discomfort, or discharge you experience related to sex. Track things such as how long it lasts, what activity may have caused the problem, and the level and nature of pain you felt.
Sexual responsiveness is a natural process, not a right reserved for special people. If you’re experiencing troublesome changes in your sexual desire after menopause, be direct with your doctor. The problem may be hormonal (low testosterone levels) or there may be other medical reasons for the change.
If your doctor can rule out medical problems that might be interfering with your sexual satisfaction, but doesn’t seem comfortable helping you pursue a solution, ask for a referral to a specialist — in this case, an accredited sex therapist.
Turning up the heat
More than half of all menopausal women maintain the same level of sexual interest after menopause as before. In fact, you may feel less inhibited when the possibility of pregnancy no longer looms over the bed. After you can safely put away the contraceptive devices (after you have gone a whole year without a period), you can be freer to express yourself sexually.
Even though men don’t go through menopause, their testosterone levels gradually decline after 40. The physiological changes don’t happen overnight. Over time, men will notice that it takes longer for them to get an erection and that they aren’t aroused as easily, which may be good news for a woman who enjoys foreplay. Women whose partners suffer premature ejaculation can rejoice. That problem may go away and men gain lasting power as they age.
Even if you’re having fewer periods (or perhaps you haven’t had one in months), don’t give up your birth control until you’ve been without periods for a full year. During perimenopause, your hormone levels and the chance of ovulation are wildly unpredictable. It’s unlikely, but you could just have a hormonally hot month and wind up pregnant.
Dealing with a lowered libido
A healthy self-image and adult lifestyle generally include satisfying and safe sexual activity. Yet many (but not all) women are frustrated by a declining desire for sex during and after menopause. Understanding the biology behind a declining libido can help bring about a solution.
Your sex drive can decline sooner than you’d like for several reasons. Some are mental or emotional — if your self-esteem declines because of changes in your life or in your body, you may have to address that issue before you can find your old libido. Some of the reasons are physical — painful sex is nothing to look forward to. And some are hormonal — your hormones are changing, and if you’d like to maintain your sex drive, your hormones must be balanced.
Communicating with your doctor is even more important if you’ve experienced early menopause. If your doctor takes your concerns about sex lightly, find another doctor. You won’t be able to get pregnant after menopause, but you can still have a hot and healthy sex life.
Adjusting your attitude
It’s hard to feel amorous when you’re depressed. Menopause, in itself, doesn’t make you depressed, but think about the types of things happening during these years:
Kids leaving home
Parents aging and needing closer attention
You or your spouse retiring
Add to these challenges the everyday issues of maintaining a happy relationship and just coping in a fast-paced world. Now, the one thing that used to be reliable, your body, is also changing at a faster pace than it has in quite some time. Is it any wonder that sex is the last thing on your mind?
But if the lack of physical spark bothers you, you need to get rid of the emotional stressors before you can expect your libido to kick in. It may just take allocating more time to yourself. Take some time to get an exercise program off the ground. Walking regularly by yourself or with a friend can do plenty to reduce stress. Talk with friends, a therapist, your hairdresser, or minister about your challenges. Also, remember to bring up your anxiety or depression when you talk to your internist or gynecologist.
Making sure that sex isn’t a hurtin’ thing
Hormonal changes can cause the vaginal lining to become thinner, more fragile, and more susceptible to tearing and to produce less lubrication. You’re more delicate down there — a bit more tender. Vaginal connective tissue also becomes less pliant, and nerve endings become more sensitive.
The result of this biological shuffle is that intercourse may become painful. Sexual activity that used to deliver great pleasure can now cause pain instead. The thought of the discomfort may make you want to get a headache or clean out your sock drawer when your partner makes amorous advances, but all is not lost. You can alleviate painful intercourse in a variety of ways:
Maintain an active sex life. Regular sexual activity keeps blood circulating in your vulva and slows the drying process. So maintaining an active sex life helps postpone or altogether avoid the pain associated with dry vaginal tissues. This is definitely one of those “use it or lose it situations.”
Talk to your partner about the more sensitive you. Most men aren’t aware that hormonal changes trigger changes in your vulva and vagina. Explain to your partner that the two of you need to figure out new bedroom strategies that can be mutually satisfying.
Take a firm position. This is a great time to experiment with new positions for sex. We’re not going to tell you which pages in the Kama Sutra to consult, but woman-on-top positions may give you more control over your own comfort.
Use a lubricant during intercourse to help keep things moving. Lubricants can afford hours of interpersonal pleasure. Some women and their partners make lubricant application a part of foreplay. Water-based lubricants, such as Astroglide, are healthier for vaginal linings. Avoid petroleum-based products.
Sometimes women experience regular discomfort due to vaginal dryness — not just during sex. If you’re one of them, you can use other types of lubricants on a regular basis to relieve this irritation. (See the product literature for recommended dosage, and check out Chapter 7 on tips for dealing with vaginal dryness.)
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It’s not the estrogen!
Many reports and books make a huge deal about the fact that no scientific evidence links changes in estrogen levels to a declining libido. These publications then make the leap to erroneously conclude that hormones have nothing to do with libido. Although the estrogen, itself, may not play the deciding role in libido regulation, the balance between estrogen and testosterone likely makes a difference.
This subject is a bit controversial so we want to give you both sides of the argument. On one side are scientists who conclude that supplementing your testosterone during menopause increases your libido. On the other side are the lab coats who believe that the science doesn’t exist to show that prescribing testosterone is either safe or effective for women who complain of low libido.
Testosterone is produced naturally by women’s ovaries and has a very positive impact on your libido, mood, vitality, sense of well being, bone, and muscle. But, even before menopause, your body slows down its production of testosterone. After menopause, you produce about half as much testosterone as you produced during your reproductive years. So it’s not unusual for your libido to decline if your testosterone levels are too low.
You don’t want to have too much testosterone either — it can promote breast and liver cancer. Plus, too much testosterone relative to estrogen can unleash the effects of testosterone that estrogen had been keeping under control, such as facial hair, increased libido, redistribution of body fat (it moves to the middle of your body), and acne.
Some doctors shy away from prescribing testosterone as part of hormone therapy (HT) because they’re afraid of upsetting the estrogen/testosterone balance and causing unpleasant side effects. The trick, whether you’re taking HT with testosterone or not, is to keep testosterone levels high enough to avoid one set of side effects (including low libido) and in balance with the other hormones to avoid another set of side effects (facial hair or acne, for example).
Those folks in the scientific and medical communities who view testosterone as a worthy treatment for libido problems believe that the bad side effects felt by some women are caused by excessively high dosages of testosterone. Proponents of testosterone use suggest using very low dosages and maintaining a balance between the levels of testosterone and estrogen.
Talking Turkey about Testosterone
Don’t forget that men, as well as women, experience declining libido as they age! If you’re noticing changes in your sexual relationship, remember that your partner’s hormones are changing too. Men produce much more testosterone than women, but when they reach 40, their testosterone levels begin declining. However, most men don’t notice an appreciable change in their libido for about another 10 years. Around the age of 50 or so, the drop in testosterone causes men to stop having psychogenic erections (erections from just thinking about sex), and men who could have an erection at the drop of a hat find that it’s a bit harder (no pun intended) to get things moving.
So, if you’re worried because your partner isn’t pursuing you like he used to, your menopause may not be at the heart of the matter. Your partner may be going through hormonal changes of his own, even though his change isn’t as dramatic as yours. You may even find that his changes are compatible with yours. It may take him longer to reach orgasm than it used to, giving both of you more time for long, slow, comfortable lovemaking.
Keeping Sex Sexy
If you’ve noticed some changes in your sexual relationship, work with your partner to make things better. Your relationship can evolve to a new level of meaning and pleasure.
First, you need to communicate with your partner and take stock of the situation. Is it a libido thing for you? Is it a libido thing for him? Is it technique? Is it timing? You need to find out what’s going on.
As you and your partner get older and both your testosterone levels decline, it’s time to focus on foreplay. You may both need more stimulation before intercourse — take your time! And you may need to incorporate lubricants into your foreplay if you have vaginal dryness.
Don’t just focus on the anticipated orgasm (yours and your partner’s). Enjoy each moment. Take time to enjoy all the feelings along the way. If actual intercourse is uncomfortable today, or just not happening, it’s fine to enjoy other sensual activities together: a bath or shower, a massage, or watching a sexy movie together.
You may also have to use different techniques to provide enough stimulation for your man to get an erection — you may have to work a little magic to get his penis into position at this stage of his life. Hand stimulation or oral sex may be what it takes to get him started. You can also turn to books and counselors — two good sources of information on sexual techniques and other sexual matters for mature adults. Ask your doctor to recommend a sex therapist accredited by the American Association of Sex Educators, Counselors and Therapists (www.aasect.org). If you think your sexual issues are related to concerns about your relationship, look for a sex therapist who is also a licensed couples or marital therapist; many are both.
Although we baby boomers come from the “sex, booze, and drugs” generation, these words no longer work together. Take a look at some of the things that can douse your flame:
Alcohol: One drink may make you feel relaxed and less inhibited, but several drinks can put a damper on your libido, your ability to become aroused, your performance, and your ability to reach orgasm.
Heavy meals: The way to your partner’s heart might be through a gourmet dinner, but if your intended destination is a little, um, further south, go light on the eats. You can always have dinner in bed after.
Prescription drugs: Serotonin boosters, antidepressants, blood pressure pills, sleeping pills, and many other drugs frequently prescribed for women and men over 50 can take a toll on your libido — or your partner’s. Let your gynecologist and internist know what medications you take when you discuss your libido and sexual performance. Alternative medications may be available that can alleviate some of the negative side effects.
Tobacco products: The nicotine in cigarettes and other tobacco products constricts the blood vessels making it more difficult for blood to rush to your private parts. It’s harder to get aroused and harder still to experience a satisfactory conclusion.
Diabetes and other medical problems also cause loss of sexual desire and performance problems. Be sure to consult with your doctor about changes in your libido because they can result from medical conditions other than menopause.
Not all lubricants are friends with the latex condoms you will need to wear with new partners to prevent the spread of STDs. Vaseline and other petroleum-based lubricants weaken both male and female condoms. Petroleum-based products may also contribute to vaginal infections.
Starting over: The good news and the bad
Here’s the stereotype: you reach midlife, and your husband leaves you for a newer model. Does it happen? Sure it does. But are you ready for a little myth busting? A 2004 survey of divorced men and women aged 40 to 79, conducted by the AARP, indicates that women are more than twice as likely to initiate divorce in midlife than are men.
Women have a longer life expectancy than men, too, and are more likely than men to rejoin the ranks of the single when a spouse dies. About 4 percent of women between the ages of 45 and 54 have been widowed. For women between 55 and 64, though, this figure has risen to almost 12 percent.
No matter how you get there, romance doesn’t have to be a thing of the past when married women become single again. Three-quarters of divorced women in their 50s, for instance, went on to have a serious sexual relationship. Many describe their sex lives at this stage as being better than ever.
Still, sex with a new partner (or partners) is not completely without its complications. It may have been years since you popped your last birth control pill or wrestled with your last diaphragm, but there are still potential risks associated with sex with a new partner:
There are a lot of ugly bugs out there: neither chlamydia, human papilloma virus (HPV — some forms of which cause cervical cancer), gonorrhea, syphilis, hepatitis B, hepatitis C, nor genital herpes care how old you are. Menopausal women (and their partners) can still get STDs — sexually transmitted diseases.
HIV, the virus that causes AIDS, is age-blind, too, and becoming more prevalent in older people as the population ages but stays healthy enough for sex. Ten percent of the people newly diagnosed with HIV every year are over 50.
The great estrogen flight changes the environment in your vagina, making it easier to contract vaginal infections. Some of these — such as bacterial vaginosis or viral vaginitis — aren’t necessarily caused by sex but are more common in sexually active women. Anecdotal evidence suggests that some of these may be more likely to occur when you’ve been with a new partner or partners. Others, such as trichomoniasis vaginosis (“trich”), can be passed among sexual partners (you and your partner must both be treated with oral antibiotics if you get trich).
Flirting with Fertility
For most of us, our menstruating years have been pretty much synonymous with the years when we expected to be able to get pregnant if we wanted to. We might have spent a chunk of this time wishing to conceive. Or fervently hoping not to conceive. Or dreaming of a little magic switch that could turn our fertility off and on according to our desires and circumstances, with none of the hassle, mess, or potential side effects accompanying our contraceptive options. If men were the ones who could get pregnant, we’re willing to bet that medical science would have figured out a nice, neat, affordable, discreet form of birth control — years ago — but don’t get us started on that one.
As it happens, the end of fertility doesn’t coincide as neatly with the onset of perimenopause as we might think — or like. For many women at both ends of the wishing-and-hoping fertility continuum, this can be problematic.
Staying fertile after all these years . . .
Maybe you just can’t wait for menopause to bring freedom from the need to wonder and worry about birth control. Not all of today’s available methods are right for every woman. Your own personal medical history, financial situation (some of this stuff is expensive ), relationship circumstances, or personal beliefs can complicate the way you browse through the contraceptive menu. And, except for a few of our more dramatic choices (such as surgical sterilization or complete abstinence), few of our birth control options are completely foolproof.
The truth is, you can’t tell very much about the state of your fertility from the regularity (or even the presence or absence) of your periods. Unless you’ve gone an entire 12 months without a menstrual period, it’s entirely possible that you can still get pregnant (admit it — don’t you have a friend or two with a child whose middle name is “Surprise”?). Trouble is, lots of women don’t know that and quit using contraception a wee bit earlier than is medically advisable.
If you’re over 40, your risk (or promise, depending on your point of view) of pregnancy is quite low. It is not, however, zero. Among women under 40, 170 women out of every 1,000 get pregnant every year. Among women over 40, this number drops to about 11 out of 1,000 (some of these were intended pregnancies, some were not). This means two important things for you if you don’t want to get pregnant:
You have to continue to use birth control faithfully.
You have to use a method with a high degree of reliability in the face of decreasing predictability of ovulation. The “rhythm” method, for instance, never the most reliable of birth control methods even in earlier stages of your life, is downright risky if the number of days between your periods is becoming unpredictable.
Taking one more chance on the stork
Maybe, though, the signs of approaching menopause have sent you into an emotional tailspin. You aren’t alone if you are still trying for a baby when you enter perimenopause. As we’ve said, it’s certainly not impossible to get pregnant at this point, but your odds are considerably lower than they were at 30 or even 40. The hormone dance that ends in menopause actually begins years before you stop having periods. Most women don’t know what time the ball begins and are shocked when they have trouble getting pregnant in their 30s.
You may have had the same experience that we had when we were teenagers: Parents, teachers, and even friends had us believing that practically all you had to do to get pregnant was to jump in a swimming pool with a boy. Okay, that’s a slight exaggeration, but generally, getting pregnant is easier when you’re in your teens than when you’re in your 30s.
In fact, according to a recent study, a woman’s fertility begins to decline in her late 20s, rather than her 30s, as previously thought. Researchers found that even women in their early- to mid-20s have only a 50-50 chance of becoming pregnant each cycle even if they have intercourse during the peak time for conception. In your late 20s to early 30s, the chance drops to 40 percent each cycle, and by the late 30s it’s less than a 30 percent chance.
By the way, that study also finds that men’s fertility also begins to decline sooner than expected. Men begin to lose their fertility in their 30s rather than in the 40s as was once thought. So if you’re in your late 30s and your partner is five years older than you are, your chances of becoming pregnant in any given cycle could drop to 20 percent. This doesn’t mean that you won’t conceive if you’re in your late 30s; it just means that it may take a few months longer, especially if your partner is older than you are.
Tracing the yin and yang of conception
Many things have to happen correctly to make a baby:
Your ovaries must produce follicles.
The follicles have to grow big enough to release an egg.
Your hormones have to be just right for the egg to be released and survive the journey.
Your fallopian tubes must be unobstructed so that the egg can swim all the way through to the uterus to meet some nice sperm.
Your hormones must create the right type of environment for the egg to get fertilized and comfortably nestled into the lining of the uterus.
All these things have to come together for you to conceive. As you begin to experience the hormonal changes of perimenopause, it becomes more likely that one or more of these essential ingredients may be missing or mis-timed.
Taking a dipstick to your estrogen
When you seek some assistance in your bid to get pregnant, one of the first things fertility doctors do is check to see if you’re capable of ovulating. In order to ovulate, you need both the right kind of estrogen and the right amount of this particular form of estrogen in your bloodstream. This form of estrogen is called estradiol, and your doctor will take a blood sample to check your estradiol out.
As you approach menopause, your body produces less estradiol but continues to produce estrone. When it comes to producing follicles and ovulating, estradiol is the kind that counts: Without adequate levels of estradiol, your ovaries won’t produce an egg. By measuring both types of estrogen, your doctor can see whether you’re heading toward menopause or whether you have some other hormonal problems. (See Chapter 2 for more info on the different types of hormones women produce.)
Because your hormone levels fluctuate during perimenopause, you may still have periods, but you may not ovulate each month. Your estradiol levels may be sufficiently high one month and be low another month. Some months are good for getting pregnant and some months are not so good. By measuring your estradiol levels each month, your doctor will be able to see if it’s a good month for producing an egg or not.
Messing up the nest with hormones
Sometimes hormonal problems occur after the follicle releases the egg. Normally the follicle pops open to release the egg and then hangs around long enough to produce progesterone (after the follicle releases the egg, the empty sac is called a corpus luteum ). The corpus luteum eventually disintegrates.
Progesterone production is necessary for thickening the uterine lining and preparing it for the egg. If the follicle doesn’t produce enough progesterone, problems arise that can put an end to conception. If the lining isn’t ready, the fertilized egg won’t nestle into the endometrium properly.
Progesterone production slows down during perimenopause and menopause, so you may have problems making a home for a fertilized egg.
Having periods doesn’t mean you’re fertile
Even for women in their prime baby-conceiving years, the planets need to be aligned to get pregnant. But as you move into your perimenopausal years, some months you ovulate, and some months you don’t. As time goes by, you experience more and more cycles in which you don’t ovulate.
You may have a period even if you don’t ovulate.
Taking the good with the bad
There’s good news, and there’s bad news when the subject at hand is conception and the older woman. Because we don’t want you walking away from this chapter on a down note, we start off this section with a few gloomy stats and then turn our attention to the good stuff.
Around the time women hit the 35 to 38 mark (some experts say as early as 30), their fertility gradually declines, and it drops precipitously at 40. Unfortunately, around this time, a woman’s risk of spontaneous miscarriage begins to rise. By age 45, women have a 50-50 chance of suffering a spontaneous miscarriage if they conceive. Also, by the time women reach 45, the risk of chromosomal abnormalities in the baby increases to 1 chance in 25. In other words, for every 25 babies conceived by women 45 or older, one baby has a chromosomal abnormality such as Down syndrome or spina bifida.
But there are also advantages to becoming a mom for the first time after 40.Women who have waited to have families are typically better prepared for the sacrifices they need to make to nurture children. Establishing careers, entertaining friends, travel, and other interests often preoccupy life during your 20s and 30s. Now you may be more willing to make time to raise a family, be better educated and more established in your career, and be on solid financial ground.
And, hey, the perimenopausal symptom of interrupted sleep means that you’ll probably already be awake when the baby cries. You and the newborn will be on the same wavelength, and you’ll have someone to talk to when you wake up.