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Frequently Asked Questions

I’ve always enjoyed sex and I’m worried that my vagina will change after menopause. What changes should I expect?

With menopause, the ovaries stop making estrogen, which can cause your vagina to become dry and less elastic or “stretchy.” Fortunately, low doses of vaginal estrogen therapy can keep the lining of your vagina healthy. For many women, so can the regular use of long-acting vaginal moisturizers when combined with regular vaginal sexual activity. Regular vaginal sexual activity is important for vaginal health after menopause because it stimulates blood flow, helps keep your vaginal muscles toned, and maintains your vagina’s length and stretchiness.

My husband and I are in our late 60s. We have a loving marriage and snuggle a lot, but we haven’t had sex in years. Is this abnormal?

Although many couples enjoy sex in their older years, there is absolutely no “normal” frequency for having sex at any age. If there’s no conflict around sex in your relationship and the relationship is loving and intimate in other ways, there is nothing to be concerned about.

I’ve had vaginal dryness and pain with intercourse since menopause. We use lubricants and I’ve even tried vaginal moisturizers, but sex is still uncomfortable. Yet I’m nervous about using estrogen. Should I be?

Although higher doses of estrogen (the doses needed to treat hot flashes) are associated with risks, including heart disease in older women and breast cancer, the very low doses of estrogen needed to treat vaginal dryness—and which are applied directly in the vagina—are considered safe. Blood levels of estrogen in women who use only low doses of vaginal estrogen are minimally elevated compared with women not using any estrogen, and are still within the normal range for women at menopause and afterward.

I’ve been experiencing bothersome hot flashes for the past year, and I wake up almost every night sweaty and then get cold.  My sex life was fine until menopause, but I’m just not interested any more. Could the hot flashes be affecting my libido?

Bothersome hot flashes, especially if they’re associated with night sweats and sleep disruption, certainly could affect your sexual interest.  When your overall quality of life is poor and you’re tired from rustling the covers all night, sleep may take priority over sex. Although hormone therapy (with estrogen or with estrogen plus progestogen) is associated with risks, if the hot flashes are disruptive and other measures are not helpful, the benefits of hormone therapy often outweigh the risks for healthy women in early menopause. Ask your provider whether hormone therapy might make sense for you.

My libido has slowly decreased since menopause, and I’ve heard that testosterone cream will really improve my sex life. Is this true?

Studies in carefully selected postmenopausal women with low sexual desire that causes them personal distress show that testosterone treatment can boost sexual interest and activity. However, the results aren’t dramatic, and placebo cream (without any active testosterone) has been shown to have similar effects. Although short-term treatment (for about 6 months) appears to be safe, we don’t yet know about long-term safety, especially with regard to breast cancer or heart disease. Studies are ongoing, but results may not be available for several years.

What’s the difference between a vaginal orgasm and a clitoral orgasm?

An orgasm is the same regardless of where the stimulation that triggers it comes from.  In general, the clitoris is more sensitive to stimulation than the vagina and is more reliably able to trigger orgasm when stimulated.  However, in some women stimulation of the vagina may be more likely to trigger orgasm or may lead to stimulation of the clitoris.

What should a recently divorced postmenopausal woman know about safe sex?

Older age is not a protection against sexually transmitted infections (STIs).  In fact, if you’re postmenopausal and not using at least a vaginal form of estrogen, your vaginal tissue may be more vulnerable to infection than it was before menopause. Although you may think of HIV or herpes when you hear about STIs, chlamydia is the most commonly reported STI.  It’s easily cured with antibiotics but often goes undiagnosed and untreated and can lead to pelvic inflammatory disease. Gonorrhea is another STI that is easily treated with antibiotics but may go undetected. Human papillomavirus (HPV), which can cause cervical cancer, is also very common, but by age 50 many women have already been infected with HPV. Pap tests are still the recommended screening option for cervical cancer. 

Ideally, you should ask your partner to be tested for STIs before you have sex. Even then, you should use a latex condom or dental dam until you’re sure he or she is disease free and your relationship is monogamous (a dental dam is a thin square of latex rubber or silicone placed over the vulva to allow oral stimulation without skin contact or exchange of bodily fluids). Condoms can protect against most, but not all, STIs.

My husband’s interest in sex has decreased a lot as we have gotten older. Mine has not. 
What can I do?

Your husband’s lack of desire may be related to several things, and identifying the cause(s) is the first step. As in women, desire in men is affected by both psychological and physical factors.

Psychological factors could include life stressors. Is he having difficulties with his job?  Is he concerned about finances? Psychological factors also include the quality of your relationship outside the bedroom. Are you experiencing conflicts in your marriage? Might he be holding some resentments? If he’s suffering from other psychological problems, such as depression or anxiety, these could affect his desire as well.

Physical factors may also contribute to your husband’s decreased desire.  Many men may suffer low desire if they develop erection problems and feel anxious about or ashamed of their inability to get a good erection. Problems with erections are common as men age, particularly in those who smoke or have conditions such as high blood pressure, diabetes, or obesity.  In addition, many men suffer from a significant drop in testosterone as they age. This drop in testosterone, known as hypogonadism, often results in a loss of sex drive (and depressed mood and fatigue) but is often overlooked by healthcare providers.  A simple blood test can determine if a man’s testosterone levels are in the normal range.

In addition to uncovering (and addressing) the source of a partner’s decreased desire, individual or couples counseling may help a couple resume a healthy sexual relationship that has been interrupted, regardless of the cause.

I am a 49-year-old divorced mother of three grown children who has recently fallen in love with a woman. How common or uncommon is this?

It’s more common than many people realize. Although many lesbians come out in their teens or 20s, many others do so only in their 40s or later.  Some “late-bloomer” lesbians come to realize, when looking back, that they were probably always gay and simply repressed their attraction to women in earlier years. They may have written off strong feelings for other women in the past as just close friendships. However, many more women report that they were not at all aware of their sexual attraction to other women until later in life. Some may have enjoyed good relationships and sex with men and then find themselves attracted to women or in love with a female friend. Research suggests that a woman’s sexuality and attractions are fluid and may change over the course of her life.

What’s the key ingredient for a great sex life?

There is no one key ingredient; sex is not that simple. However, there are ways to increase your chances for a great sex life. For most of us these include maintaining a certain level of desire, having that desire satisfied regularly, and being glad that the partner satisfying that desire is the same person every time. A relationship like that requires work and trust. The “key” is for couples to not take each other for granted and get lazy.

Another “key” to a great sex life is variety and creativity. Without a little effort to mix things up, even the most sensational activities become routine and stale.  It’s well worth the effort to come up with new ways to express sensuality and sexuality with your partner. That might mean bringing some sex toys into the bedroom or having sex in a different environment, such as in a luxury hotel, on top of the dining room table, or in the backyard under the moonlight. For others it could mean watching an erotic video together or role-playing your fantasies.

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