Menopause and Sex

A famous New Yorker cartoon depicts a middle age couple walking together. The husband says "Now that the kids are grown and out of the house, do you think we could start having sex again?" While myths and misconceptions abound about menopausal women and libido, supermodel -and super role model- Lauren Hutton says this is a great time for women to explore and enjoy their sexuality. Dr. Donnica Moore, well-known ob-gyn and women's health expert, explains some of the physiologic and psychological issues surrounding menopause and sex. You may be pleasantly surprised!

While menopause marks the end of a woman's reproductive cycle, it does not signal the end of her sexuality. The once popular phrase "finished at fifty" is history. Some women actually feel liberated after menopause when they no longer have to worry about pregnancy or when their child-rearing responsibilities decrease. Yet, for other women, menopause brings about a decrease in sexual interest and activity. While the physical changes associated with menopause may contribute to a decline in sexual activity, it is difficult to say that they are the only factors that may affect sexual activity. Relationship and psychological status play an important role in both sex drive (libido) and sexual satisfaction.

Declining hormone levels are responsible for many physical changes that may lead to a decrease in libido and sexual satisfaction in menopausal women. Without estrogen, the vagina is less well lubricated and the vaginal lining thins. Lower estrogen levels also decrease the blood supply to the vagina and the surrounding nerves making the vagina drier. These symptoms may contribute to painful intercourse.

Other menopausal symptoms that may affect sexual desire include hot flashes, night sweats, insomnia, bladder and urinary tract problems, sleeplessness and fatigue, mood changes, and general irritability. For some women, these changes may translate into a decrease in self-esteem and eventually a loss in sexual desire.

As with any age group, relationship status may also affect sexual activity. Communication is the most important success factor for any relationship. Yet menopausal women may face other relationship issues, especially women without partners. For example, at age 65, women outnumber men by 25 percent. In addition, as men age, the male sex hormone testosterone diminishes causing a decline in their sexual desire and performance capabilities.

In no other arena is the saying "don't worry, be happy" more applicable than in the sexual arena. Many sex therapists find that concerns, worries and fears about sex are usually bigger problems than any physical or sexual changes themselves. Whatever the biological problem, your attitude will be the most important determinant of how well you and your partner cope. At this point in life, the brain remains the most important sexual organ. And common sense goes a long way in resolving sexual issues related to decreased libido or decreased sexual satisfaction.

For example, a healthy lifestyle, in general, can boost confidence and improve sexual desire. Physical or mental illness may slow sexual response, whatever its cause. As with most conditions, regular exercise, regular sleep, and eating a balanced diet can improve outcomes- as can stopping smoking (it's never too late!) and limiting alcohol intake. Alcohol may help you get "lucky" getting into bed, but it won't help you once you're there!

While truly menopausal women are no longer at risk for unintended pregnancy from unprotected intercourse, a dangerous myth is that menopausal women are no longer at risk for sexually transmitted diseases (STD's). This isn't true. Menopausal women may be less likely to get pelvic inflammatory disease (PID) than younger women, but they are still at risk for virally transmitted STD's such as HIV/AIDS, herpes, genital warts and hepatitis B. Condoms are still recommended for any sexual intercourse outside of a mutually monogamous relationship.

Another prevailing myth about menopause is that it is associated with "empty nest syndrome" and causes depression. Research has shown that the incidence of depression in women actually peaks in the 30's; on the contrary, many women in their 50's experience what Margaret Mead termed "postmenopausal zest". Menopause is a risk factor for depression in certain women however, women who have had a previous history of depression (including postpartum depression), women with any other psychiatric illness, women with a family history of menopausal depression, and women with a history of premenstrual dysphoric disorder (PMDD, otherwise known as "PMS"). Depression can also be a symptom of numerous other medical disorders, from hypothyroidism to heart disease to infectious conditions; any menopausal women with depression should consult their physician, rather than assume it's "normal" to become depressed when one enters menopause. What if your doctor's diagnosis is depression? Remember- it is treatable. Depression is not only a major cause of decreased libido and sexual satisfaction but decreased libido and decreased sexual satisfaction are early symptoms of depression.

Unfortunately, some of the common medicines used to treat depression may also impact your sex drive- or your partner's. Other common medications such as medicines for high blood pressure may have the same effect. Talk with your physician about this; there may be simple changes that can be made which can have very positive outcomes. It's also important-although it may be embarrassing--to talk with your physician about any physical difficulties you may be having related to menopause that may impair your sexual activity. Many of these difficulties can be improved or resolved with medical therapy, such as hormone replacement therapy (HRT), vaginal lubricants, aids for incontinence, or making changes to existing medication regimens.

It is clear that HRT has a positive benefit on treating menopausal symptoms in the short term (less than 5 years), which in turn may improve sexual desire and satisfaction. Some studies have also shown that a combination of estrogen and testosterone, the male hormone that women normally manufacture, may improve sexual desire. All medical treatments have advantages and disadvantages, however. Results from the Women's Health Initiative indicated that women whose average age was 63.5 who took a combined estrogen-progesterone combination therapy had an increased risk of invasive breast cancer, heart attacks, strokes, and blood clots. The estrogen-testosterone replacement may also reduce the cholesterol benefits that estrogen alone provides and have other side effects. More studies are needed to evaluate fully the benefits/risks of combined estrogen-testosterone therapy, as are studies to elucidate the benefits of estrogen or its alternative therapies on menopausal sexuality in general. Only your physician can give you individual recommendations as to what's best for you given the information we now have and your own personal risk profile.

One approach to learning more about menopause and sexuality is to ask menopausal women themselves. According to a recent survey of 1001 women by Yankelovich Partners (sponsored by Wyeth-Ayerst Laboratories), a majority of women ages 50-65 say their sexual desire and interest in sex is just as robust or has increased since before menopause. Menopausal women surveyed cite greater overall balance in life (77%), less child-rearing responsibilities (61%), and decreased risk of pregnancy (52%) as key reasons for maintaining their sexual energies. Another interesting finding was that of this group, women taking hormone replacement therapy (HRT) reported greater sexual activity than their counterparts not on HRT.

The findings of the survey make sense medically -- HRT can relieve the symptoms caused by reduced estrogen levels that can make sex uncomfortable for many women after menopause, including hot flashes, sleeplessness, night sweats and vaginal dryness. According to the survey, women who have partners but are not on HRT cited menopausal symptoms and low sex drive as reasons they may be having less sex now than before menopause, which may explain why more women on HRT are enjoying sex more.

Contrary to "conventional wisdom" -i.e. myths- surrounding menopause, more than 87% of the women surveyed have a positive attitude toward menopause. These women also play an active role in managing their health-they indicated that good nutrition (98%), exercise (95%), and plenty of rest and sleep (91%) are some of the keys to remaining healthy and vital during and after menopause. Of the women surveyed, 80% reported feeling more independent and in control of their lives since entering menopause.

When comparing sex before and after menopause, 82% of women taking HRT said that their sex life improved or has stayed the same, whereas only 68% of women not taking HRT feel the same way. The women on HRT cited comfort with their partner, physical fitness, no fear of pregnancy, and HRT as the top four reasons for their satisfying sex life. Perhaps most interestingly, the majority of women on HRT said that their HRT (60%) is more important than sexy lingerie (35%) to maintaining their satisfying sex life.

There is so much that women can, and should, do to protect their health-physical, emotional, psychological, and sexual--during and after menopause. Exercise, nutrition, good relationships and a positive attitude will all help women live vital and healthy lives. Sex is just one part of the equation. Women entering menopause and even those already in menopause should speak with their doctors-and their partners--about what's best for them.