“Hear Me Roar!”:
Female Sexual Changes
As we approach the topic of female sexual changes that occur with aging, we’re reminded of some lines of the Helen Reddy song that became somewhat of a feminist manifesto in the 1970s:
I am woman, hear me roar
In numbers too big to ignore . . .
You can bend but never break me
’Cause it only serves to make me
More determined to achieve my final goal
Oh yes, I am wise
But it’s wisdom born of pain
Yes, I’ve paid the price
But look how much I’ve gained.
By the year 2030, 1.2 billion women in the world are expected to be age fifty or older. During the 1990s, approximately 24.5 million women worldwide reached menopause each year. In the U.S. and Canada alone, approximately 4,000 women reach menopause every day.1 These numbers really are too big to ignore.
But what’s the roar? That depends on the woman. Some women will respond with growth as they face the adversity of life, using the challenges presented by physical changes to gain the “wisdom born of pain” and develop a healthier new identity. For others the roar may represent their frustration, complaints, resentments, and losses as they unsuccessfully battle the aging process.
The key word that describes the shift in sexual function for women at midlife is change.A woman may experience her sexual desire subsiding or she may find desire increases.As a result, her frequency of sexual activity may increase or decrease. She may also experience an increase or a decrease in the sensitivity of her clitoris, and her sexual responsiveness may also go up or down. A wife may find that she experiences fewer orgasms and with unpredictable intensity, or she may realize an increase in orgasms and a sexual awakening.2 It is impossible to foresee how an individual woman will experience midlife sexual changes, but we can predict that what was normal before may not be now. Many women will not experience a decrease in sexual desire during menopause, but when they do it is often due to hormonal imbalances, negative thinking, relational problems, or other stressors. The sexual changes in women may be less noticeable, but they are more variable and complex than the changes in men.This chapter will address female sexual changes that can occur from midlife onward, and in the next chapter we will focus more on the hormonal changes of menopause and how sexual response may be impacted accordingly.
PHYSICAL CHANGES
Thinning and Tightening of the Vaginal Wall
As levels of the sex steroids, estrogen and testosterone, begin to fluctuate, changes may first be noticed in the genitals. Dropping estrogen levels will cause the vaginal walls to thin, and they will not have the same elasticity and soft padding.The vagina may shrink, with its mouth becoming narrower.
Because the vagina has lost some of its cushioned effect, some women will experience urethritis (sometimes called the honeymoon disease, it is an irritation of the urethra and bladder from the penis hitting them during intercourse). The labia minora and labia majora (inner and outer vaginal lips) can also atrophy, thus leaving the clitoris more exposed. This means that direct stimulation of the clitoris can become painful.
Vaginal atrophy is a consequence of diminished estrogen production and/or lack of use. Many women have thus benefited from estrogen replacement therapy (ERT) and/or estrogen creams, which aid in restoring the vaginal wall and improving lubrication. It is possible to increase vaginal muscle tone by regular Kegel exercises, which involve pubococcygeus (PC) muscle contractions. These exercises are also very effective in maintaining vaginal blood circulation.Two hundred Kegels a day will go a long way in preserving the vaginal tissue by increasing blood flow to the area.3 Adding more soy products to your diet is a natural way to boost estrogen, as soybeans contain phytoestrogens, which can rebuild and moisturize thinning vaginal walls.
Time Out: Here are two different types of exercises that you can practice to strengthen your PC muscle. They are easy to practice while in the car, on the telephone, or watching television.
1. Become familiar with your PC muscle (which goes from your pubic bone to your coccyx/tailbone and is the muscle you would contract to stop urinating) as you contract and immediately relax it. Do this rapidly five times as you inhale and then exhale. Repeat five times.
2. Pretend your husband’s penis is at the mouth of your vagina and you are trying to suck it into your vagina by pulling with your PC muscle. Pull for three seconds and relax. Repeat ten times and then rest.
Decrease in Vaginal Lubrication
The loss of estrogen can affect lubrication too. It may take longer to lubricate, and the amount may be less. While in the past it may have taken seconds to create arousal and sufficient lubrication, it may now require several minutes of love play (for some women, dryness will require artificial lubrication). Vaginal dryness can be helped by regular Kegel muscle exercises in that as you increase blood circulation, natural lubrication will be enhanced. There are a variety of lubricants that can be used during intercourse to reduce irritation and friction. Begin by trying water-based lubricants like Astroglide, Gyne-Moistrin, Moist Again, Probe, and Aqualub, to name just a few on the market. Some brands like Wet or Eros market both a water-based or oil-based formula. Replens is a moisturizer and lubricant that helps restore a proper pH in the vagina as well as actually plumping up the tissue. Don’t use oil-based petroleum jelly (Vaseline), as it doesn’t clear easily from tissue and can result in infection. Women who are sensitive to yeast infections should also avoid the oil-based preparations.
Daily intake of zinc (15 mg), vitamin E (400 IUs), essential fatty acids (salmon, tuna, evening primrose oil, black currant seed oil), and other herbal extracts can often help improve lubrication.4 When possible, avoid the substances that dry up membranes, such as antihistamines, diuretics, alcohol, and caffeine, as they also will dry the lining of the vagina. And don’t forget to drink eight glasses of water a day.
Dyspareunia (Painful Intercourse)
This is the most common sexual complaint in older women. It’s not hard to understand why this may be the case, with the loss of a cushioned vagina that is also less lubricated. Changes in the vaginal mucous membrane can increase one’s vulnerability to infections that can provoke pain during intercourse. In addition, pain may be the result of a change in uterine contractions. The uterus experiences atrophy as a result of lower estrogen levels, so during orgasm, the uterine muscle contractions that used to be smooth and pleasurable become more spastic and painful.5 Again, estrogen replacement will often restore full sexual functioning without pain for many of these problems. Estrogen replacement and other options when ERT is not possible or recommended will be discussed at more length in the next chapter.
Decrease in Frequency of Sexual Desire
As we mentioned earlier, there can be significant individual variation in how aging impacts desire and sexual frequency in women.What seems to account for the difference? Testosterone, in women as well as in men, seems to be “the libido hormone.” It is likely that some of the desire changes in women are linked to a fall in testosterone, since the level of this hormone also drops along with estrogen. If a woman experiences low levels of sexual desire in the absence of relational problems or conflict, she should be encouraged to ask her physician to have her free testosterone level checked. If it is in the low range of normal, she may benefit from testosterone replacement. It can be formulated as a cream to be applied in the vulval area (but not before intercourse), or applied as a gel to the shoulders.
RELATIONAL ADJUSTMENTS
These physical symptoms of aging may diminish sexual enthusiasm and comfort in lovemaking.Couples will need to creatively address these issues for intercourse to be possible, let alone enjoyable. Because arousal and lubrication will often take longer, it is important for the couple to use the extra time to create an atmosphere that facilitates loveplay on this more relaxed journey into intimacy. Intercourse may need to be gentler at first and care taken on entry. Artificial lubrication ceases to be optional, as more liberal and frequent applications are necessary to counteract some of these physical changes. The husband may need to be more charming and alert to what pleasures his wife, so she feels cared for and open to his sexual advances.
It may take longer to reach orgasm, and its intensity and duration can diminish. However, even if the orgasm is less intense and takes more time to occur, a woman’s ability to have multiple orgasms remains the same with age and, unlike in men, her refractory period does not extend.6 With aging, he will need more time also, so this becomes a great time for the couple to relax and explore each other’s bodies and begin to discover what each enjoys.
A difficult paradox exists with regard to female sexual changes and intercourse. On the one hand, regular sexual activity can contribute to a delay or reduction in the physical effects that begin at midlife. Sex enhances vaginal lubrication, reduces vaginal thinning, maintains the muscle tone of the vagina, and increases the blood supply to the vagina, helping to prevent atrophy.Women who have sexual intercourse once or twice a week before, during, and after menopause also tend to have fewer sexual dysfunctions.7 The paradox is that it is often difficult “to use it or lose it” if one is experiencing painful intercourse, infections, vaginal dryness, low energy, sleep disturbances, depression, concern about attractiveness due to a change in body image, and overall lowered sexual desire.
To resolve this paradox will require regular and clear communication with patience and understanding between partners.The majority of complaints concerning sexuality in aging adults are produced by a lack of knowledge of the normal physiological changes linked with age and an inability to communicate needs and preferences. Women, in particular, have difficulty identifying and expressing their sexual needs.8
When it comes to sexual response, perhaps even more significant than the physical and hormonal changes a woman experiences with aging is what occurs in her thoughts, feelings, and relationships.The combination of menopause, the changing roles of an empty nest, and an inability to have an orgasm can cause some wives to come to the erroneous conclusion that they are “too tired” or “too old” for sex. Many times this is because sex is perceived by the woman as another instance where someone is taking from her and she is not receiving a tangible benefit. Everyone tires of constantly giving when there is little received in return.This mind-set will pollute her perspective on sex, and her spouse will need to be very involved in restoring her joy.
Many women may struggle with long-standing sexual inhibitions, have experienced sexual abuse or victimization, have fears about losing their attractiveness, or be in an unsatisfactory relationship. Perhaps after many years of marriage, predictability has replaced spontaneity, and sex has become routine and mechanical. Sex therapy or counseling may be helpful in these situations.
So much of sex is in the head.This can be a rich time for you sexually; you have lost some of your earlier inhibitions and know more about what arouses you. Pregnancy is no longer a fear.You may have to engage in some self-talk about your attractiveness as your body loses its firmness and skin tone decreases. Again, maturity can be associated with greater skills and more comfortable attitudes. Older women make great lovers,but they may need their partners to help convince them of this fact.
Remember how we began this discussion: “I am woman, hear me roar.”As you work to accept the many physical changes in your life, what kind of roar will be heard from you?