Midlife sex: The new normal

If you could see your sex hormones pulsing through your body right now, you'd witness a minute symphony of chemicals and hormone receptors playing on a molecular scale. After menopause*, the orchestra becomes even more Lilliputian.

The power this tiny universe of cholesterol derivatives wields upon your body, your brain and your sex life is outstripped only by your ability to overestimate the impact of its actual effects. (Consider the case of a certain fountain of youth-chasing/former Three's Company star whose ThighMaster sales have gone the way of the Chia Pet, and who hoovers estrogen like a teenager chugging Red Bull at a rave.)

Which is why it may be news to some that, as you age, changes in your body and libido aren't a disease; they're normal. So too is the decision to seek treatment that will help you shag like a bunny until you're 90. Also normal? Forgoing intervention altogether and still checking every erotic fantasy off your sexual to-do list, or never having intercourse again. Bottom line: It depends not on your hormones, but on what your heart says.

This is your sex life on menopause.

Your libido on menopause

"We talk about sex here."

So say the signs on the doors at Winnipeg's Mature Women's Centre in the Victoria General Hospital. Richard Boroditsky, the centre's medical director, is the one who put them there. "The biggest reasons we get women consulting us is for low libido, painful sex, decreased sexual desire and the lack of an available functional partner," he says. "Less than 15 per cent of these women ever wind up needing intensive sexual therapy."

The libido-dousing effects of husband-hating notwithstanding, Boroditsky cites other psychosocial factors as prime suspects in the instance of low sex drive: stress, ingrained repressive attitudes or not being turned on by a partner. Case in point: "I once asked a woman if she was sexually active," says Boroditsky. ‘No,' she said, ‘I just lie there.'"

Throughout adulthood, most of us experience a gradual arousal overhaul as our ovaries slow their production of testosterone. Testosterone is the chemical largely responsible for sexual response, desire and fantasy, and lower levels may mean a kinder, gentler sexual response. Or to put it another way: "Basically, that spontaneous horniness you had in your twenties? It's gone," says Boroditsky. "It's normal for your sexual response to become a bit slower; you need more stimulation emotionally and physically, and your orgasms can take longer and lose intensity."

But don't be too quick to run to the pharmacy for some prescription testosterone just to get your twentysomething horn dog on. "There are so many other factors that can decrease libido that testosterone is often not the answer," says Boroditsky. Then again, for a small group of women who are extremely low in testosterone as a result of surgical removal of their ovaries, chemotherapy or radiotherapy, or for those in fulfilling relationships but experiencing an unexplained sexual dullness, low doses of testosterone—much lower than replacement doses for males—may do the trick. "For these women," says Boroditsky "the difference is like night and day. It's unbelievable."

Your vagina on menopause

There's a reason aging penises are supposed to get softer as our vaginas grow older.

Picture your premenopausal vagina as a robust, estrogen-bathed organ with plump, self-lubricating walls and cervix, and an army of lactobacillus bacteria that keep the environment cozily acidic and free of harmful bacteria.

Now picture your post-menopausal hoo hoo with less estrogen, less lubrication, a sliding pH balance that opens the door to infection, and a vaginal lining rivalling the thickness of prosciutto.

"Decreasing levels of estrogen can thin the lining of the vagina from 13 cell layers thick to just one or two," says Wendy Wolfman, director of the menopause unit at Toronto's Mount Sinai Hospital. This thinning, says Wolfman, along with decreasing levels of collagen and elastin in the wake of the estrogen retreat, can make the vulva tender and the vagina more prone to trauma and injury, such as tearing and bleeding, during intercourse. Nice.

Oh, and falling levels of estrogen can also turn the environment more alkaline, weakening your protective bacterial vanguard and leaving you more vulnerable to urinary tract infections. Now there's a turn-on.

Did we mention that prolonged abstinence from any kind of arousal, orgasm or intercourse—on top of plummeting estrogen, collagen and elastin levels—decreases blood flow and actually shrinks the vagina's opening and length? Really.

Halting hormonal free fall

"There's a lot of hormonal variation between women—some at the high end, some at the low," says Wolfman. "But it's normal for your estrogen levels to be lower after menopause and to have no progesterone, since there is no more ovulation." After reviewing all of the options, Wolfman and her team often prescribe short-term hormone therapy for their patients, most of whom are referred to the unit by their GPs because of extreme menopausal symptoms. "It's very safe for early menopausal women. There appears to be no increased risk of heart disease or stroke in healthy women between 50 and 60, and it's a wonderful medication to improve the quality of a woman's life."

Or you can go local. Boroditsky at the Mature Women's Centre has addressed urogenital aging by prescribing vaginal estrogen rings, pills and creams, which can be used at very low doses indefinitely, as well as non-hormonal moisturizers such as Replens, a gel that draws fluid into the vagina, helping to restore its original elasticity and moisture. "We have a lot of success with using estrogen in the vagina," says Boroditsky. "It works beautifully."

Or you can do nothing at all. "Many women are perfectly happy not having intercourse, while others notice a huge lack," says Wolfman. "Sometimes it's the man pushing a woman to our clinic to get 'help.' But [seeking treatment] is an individual decision. If a woman's interest isn't there and she's happy, we shouldn't try to make her sick if she's not."

Which leads us to Boroditsky's mantra: "We spend a lot of time explaining that sex is way more than intercourse," he says wearily. "Any form of sexual arousal and eroticism can keep the vagina healthy. Orgasm itself will ensure increased blood flow, elasticity and moisture in the vagina. And the fact is, most women don't orgasm with intercourse alone, anyway."

In fact, Boroditsky's most resoundingly successful "treatment" is simply telling patients that what they're going through is normal, and giving them permission to forget about intercourse and instead focus on every other form of pleasuring that makes them aroused. "Once they change their focus, their sex life is just as good, if not better than, before," he says. "Many women simply talk to their partners after our appointment, saying, 'This is what I talked about with my doctor,' and often male partners are relieved. These men were worried they were hurting their partners. It really takes the pressure off."

Your patient/doctor relationship on menopause

Aline Zoldbrod, a Boston-area psychologist, sex therapist and author, strains to find the most delicate way to describe the degree of sexism and ageism she witnesses among GPs when dealing with menopausal women and their sexual health. "In some instances, it's as though they look at you, and if they don't particularly want to have sex with you, they think no one else will, either."

Zolbrod has reason to be critical, if not indelicate. A survey from the Women's Sexual Health Foundation in the U.S. found that less than nine per cent of respondents said their healthcare provider regularly initiated discussions about sexual health problems. The survey also found that when they did broach the subject with their docs, almost 20 per cent of women were told that sexual problems were, essentially, "all in their head." "With men, they just throw Viagra or Cialis at them. With women, it's sometimes, ‘You're getting older. What do you expect?'"

Although Canada lacks specific stats, doctors here may not be any more enlightened. "Most physicians think it takes too much time to deal with these concerns, or think they don't have the expertise, or aren't comfortable talking about sexuality because of their own issues," says Boroditsky. "So they never even ask the question, which is tragic because most women want to talk but never get an opening."

If your sexual health is going to be on the table at your next appointment, it's up to you to forge that opening. Get informed: Try resources such as menopauseandu.ca or your closest women's sexual health or menopause unit. And if that doesn't work, drop that doc like the tube of K-Y he dismissively suggested when you reported that intercourse now felt more like impalement. "Make sure you have a doc who takes this seriously," says Zoldbrod. "Look for someone who asks you lots of questions, gives you an understanding of the natural process your vaginal tissues are going through, and goes through all the options with you. Yes, all these changes do happen naturally, but there are many ways to intervene and lots of options."

Sex after 40 isn't all downhill: Sex ed for midlife, what to share with your kids about your sex life, and get fit for better sex!

*This section uses the terms “menopause” and “menopausal” in reference to the time leading up to, during and following menopause. Medically speaking, perimenopause represents the three to 10 years leading up to menopause. Actual menopause is a marker in time, exactly 12 months after a woman’s last period. Anything after that is technically referred to as post-menopause.

This article originally appeared in the November 2009 issue of More