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Few things in life are fun and free. Sex is one. As Henry
Miller said, “Sex is one of the nine reasons for reincarnation...the
other eight are unimportant”. Just as lack of sex begets even less
sex, reinstitution of sexual relations begets more sex. Like with potato
chips: “...bet you can’t eat just one...” (no pun intended).
SEXUALITY AT MIDLIFE:
It is hard to fight nature, but in the case of sexual and sensual enjoyment,
it is a fight worth engaging. Our genetic engineering, oriented towards
preservation of the species, doesn't’t mind if our sexuality withers
after fecundity declines. But if we don’t use it, we lose it. Several
things conspire against us:
1. Women’s Issues: It is hard to
feel sexy if you are flash-flushing all the time, moodiness is your
middle name and the last time you had a restful night’s sleep
was sometime last July! Then, if you get past all that, what’s
about this dryness thing? Sex is not supposed to hurt. It is supposed
to be pleasurable. Isn't it??
It is hard to feel sexy when your teenage daughter tells you how much
cellulite you have and how much weight you gained; when size eight is
a distant memory and when your aged mother calls (the third time today)
to say your dad has slipped and fallen in the bathtub.
You used to love sex (or at least like it a fair bit). Now you could
care less if you ever get any again or not. Maybe once you get started
(if your arm is twisted) you do get aroused (sort of...)--and orgasms
are still quite satisfying (even if it does take longer), but sex is
nowhere on the “priority list”. (Didn't always used to be
like that...). You feel sorry for your husband. Poor guy--he hardly
asks anymore, he has been turned down so much. What is worse for him
is to be accepted--but feel like he is being accommodated. It was some
time last month when you last had sex!
2. Men’s issues are divided into
the “want it but know she-ins't-gung-ho-so-what-do-I-do?”
situation, the “well I'm not really interested either” bag,
and/or some variation on the “can’t get it up/can’t
keep it up” theme.
Just as hormonal issues--the sudden variations and loss of estrogen
production and the slow steady decline of testosterone-- impact a woman’s
sexuality, testosterone loss frequently impacts men with loss energy
and libido as well.
3. Medication and Health Issues: Some of the medications
we (both men and women) take as we transition through midlife tends
to have significant effects on both sexual interest and ability to orgasm.
Mood and depression difficulties (which in itself can diminish desire)
sometimes result in administration of anti-depressant medication. This
may be a double-edged sword. At the same time as anti-depressants, such
as Prozac, Paxil, Zoloft, Celexa, Lexapro and Effexor, make life smoother
and easier to live, they may, to a greater or lesser degree, diminish
sexual desire and responsiveness in both women and men.
Other medications, most notably certain antihypertensives (blood pressure
lowering medications), may have similar effects, especially in men.
4. Discomfort Issues: As if all of the
above weren't enough, one of the greatest banes of midlife sexuality
for women is the loss of vaginal lubrication, dryness and discomfort
with the stimulation of lovemaking.
The vagina is exquisitely sensitive to estrogen. Remember how “juicy”
you were when you were pregnant with estrogen levels skyrocketing? Likewise,
one of the earliest heralds of the falling estrogen levels of midlife
is vaginal dryness and sensitivity. Remember when (aahhh!) you used
to get “wet” when you had a sexual thought (oh, c'mon now—it
wasn't that long ago!). That clear, sticky liquid just outside the vagina
was secreted by your Bartholin’s glands, providing outside lubrication
for enjoyable intercourse.
Unfortunately, these glands regress with the diminishing
estrogen levels of midlife, and their secretions are minimal. Tissue
thinning, less secretions inside and out: not a very sexually inviting
situation, and one that leads to irritation and tearing of the sensitive
tissues just outside of the vagina.
5. Men and women are different: (So,
what else is new?) Actually, this is important if you are to progress
past midlife sexual ennui.
The Masters and Johnson model of sexuality (desire leading
to arousal leading to intimacy, plateau and orgasm) is a male model. Women
are different, as described in the more accurate Basson model of female
sexuality. In Dr. Rosemary Basson’s model, intimacy comes first
(the opposite of the male model). An understanding of these principles
is important if sexual intimacy is to be reestablished.
Men and women are different. Desire is the initiating factor
for men (no desire/no erection); it is not necessarily so for women. Nothing
wrong with that. As you will see, delightful sexual intimacy can evolve
outside of the genesis of “desire”. Unless low testosterone
is a factor, most midlife men walk around in a more or less continual
state of desire. If something occurs—such as an erotic image, the
curve of a breast, imprint of nipple, flash of eye or thigh—that
man gets aroused, and he desires...intimacy!
It is just the opposite with women. Most women don’t
get turned on if their husband walks around in his skivvies. Women's sexuality
is "circular." A woman's sexual response begins with availability;
in order to be "available," there must first be trust and intimacy.
Then, if there is some physical intimacy (touching 'n cuddling...)there
just may be arousal... and desire for sex. Men are linear: desire?arousal?
sexual intimacy. Women, circular: availability/intimacy?arousal?desire.
(And, if sex is satisfying, this leads 'round again to availability.)
These things are normal. They are the “way of life”. But they
certainly effect sexuality, sexual desire and satisfaction. To change
requires conscious effort. All of this doesn't seem to come naturally,
but the prize can be sweet.
HERE IS WHAT YOU CAN DO
Vaginal dryness and discomfort: Easy. Just as the vagina is sensitive
to lowered estrogen levels, it recovers just as quickly. “A little
dab’ll do ya...”. Replens is an easily available over-the-counter
vaginal moisturizer. If this is inadequate, a small amount of estradiol
or estriol cream, estradiol tablets, or a small in-place estradiol-releasing
vaginal ring can all, in short order, rejuvenate the vaginal mucosa (lining),
with minimal systemic absorption (if you want increased absorption, increase
There is a second and separate issue, however. Penises don’t
shrink to accommodate the thinning, mild atrophy and dryness of approaching
menopause (welll...sometimes they do...), and a woman’s introitus
and perineum frequently become traumatized. Since your Bartholins aren't
doing their thing to make you slippery, you may now have to supply your
own lubrication, but there is nothing wrong with that, and it can even
There are lots of sexual lubricants on the market, and they
come in names like “Silky”, “Astroglide”, “personal
lubricant”. All of these products are water-based and use glycerol
and propylene glycol for their active ingredients, which means that they
are cool and eventually become tacky and dry out. They are usually used
on an as-needed basis to, well, help things “slide in”. Not
My suggestion is to use either a mousse (like "Intimate
Options"), a silicone-based lubricant, or a light oil.
Unless you are using a condom, or plagued by recurrent vaginal infections,
I recommend a light oil--massage oil, light olive oil, mineral oil...baby
oil is great. Have a little bottle at the bedside (or wherever...). Each
of you can put a little on your palms, rub them together to warm the oil,
and...Play! I am sure neither of you would mind much if the other sensuously
applies some oil to all of those parts you like stroked. You can talk
and fantasize as well. This leaves a thin coat of oil (which will not
dry up) on the various parts that will benefit from lubrication and it
becomes much more than just applying lubrication at the last minute so
that...”it goes in easier”.
Other great ideas: Besides the vaginal rebellion that occurs
in women when their estrogen goes south, the combination of insomnia,
mood swings, hot flashes and other disturbances resulting from low estrogen
levels couples with the direct effect of diminished estrogens to impact
women’s sexuality. Testosterone levels frequently have been going
down also (one-half of a woman’s testosterone is secreted from her
ovaries—the other half converted from the adrenal glands). This
combination can be a 1-2 punch which can be a particularly heavy knock
out for those women who experience surgical or chemotherapeutic menopause.
Estrogen supplementation can be a lifesaver here.
Have your testosterone checked also and supplemented if
your bioavailable testosterone is low. A serum (blood) testosterone alone
is worthless here. Only 1% at best of the testosterone circulating in
a man or woman is utilizable by the body—the rest is bound to the
blood proteins sex hormone binding globulin (SHBG) and, to a much lesser
extent, albumin. A woman (or man) can have a low-normal or normal testosterone,
but a normal or upper normal SHBG and a healthy albumin and have very
little bioavailable testosterone. Salivary testing may also be of benefit
here, since in order to get into the saliva, the testosterone must be
available to the salivary gland to be incorporated into its secretions.
Signs of possible diminished testosterone in women are low sexual desire,
more difficult arousal, loss of energy and a general decreased joie d’vivre.
Men can be in the same boat here. Although a man’s
testosterone levels are maintained longer than a woman’s, the same
thing (lowered testosterone coupled with not lowered SHBG and albumin)
lead to only a fraction of 1% of his total testosterone being available,
leading to decreased sexual desire, “oomph” and energy and
also leading to poor response to erectile agents (if testosterone is low).
Again, a simple blood testosterone is worthless. Testing
must include total testosterone, SHBG, albumen (+/-) and free or bioavailable
testosterone. Salivary testosterone as well is nice, to see if it is concordant
with blood values and is also good to easily follow results of therapy.
Most readers still with me to this point know the uses of
erectile agents (Viagra, etc.) in men. What you may not know is occasionally
they find usage in women as well—specifically in women with peri/postmenopausal
arousal or orgasmic difficulties, who had no such difficulties when they
were younger. These agents do nothing for “desire”, however,
But, you know, you can have great sex without desire. Don't
beat yourself up if you feel your desire waning. Read on, read on!
“DATES”: Remember when you used to go out on
dates? How maybe you would look forward to a little nookie at the end
of the evening? Well...resurrect that concept! Here is a great way to
resuscitate your barely existent sex life, and put matters “on your
If you are like so many of my patients, your answer to the
question of when you last had sex is an embarrassed “...sometime
last month...” Remember: “Use it or lose it.” Remember
that (once dryness and lubrication is corrected) it is sorta nice...once
you get into it. Remember the bind your husband or lover is in. “...To
ask or not to ask...” Remember the discrepancy in the “...Desire/intimacy
You can put matters on your turf! Schedule Intimacy First.
Take the pressure off and have fun. Here is how:
At least once per week (if you are having sex every month or so) or twice
a week (if your present frequency is about once every week or so) SCHEDULE
(--on the calendar—inviolable--) time for physical intimacy. At
least an hour. Daytime or early evening (not squeezed in late at night).
A time when the kids will be out of the house (or you can arrange to have
them out—with a “wink” if needed) in bed (or the comfortable
place of your choice). Scanty clothing and/or “special garb”.
Oil, music, “toys”, erotica, etc., all at the ready.
foreplay can begin at the beginning of the day, taking extra care to...be
nice to each other).
The pressure is off both you and your partner. He does not
have to worry about being rejected. You don’t have to worry about
lack of desire as, in this scenario, desire is not the initiating factor.
It is on your turf. It puts intimacy first and of course does not preclude
other (non-scheduled) interludes.
Also--it is never too late for “new tricks”
and explorations. There are many websites
specializing in sex toys and erotica. Go to the erotica section of your
local bookstore and browse. Anything written or edited by Lonnie Barbach,
PhD, is good. (Re-)explore “The Joy of Sex” and “More
Joy”, both written by Alex Comfort. Many books, including “Getting
the Sex You Want: A Woman’s Guide to Becoming Proud, Passionate,
and Pleased In Bed” by Sandra Leiblum, PhD, “How to Have Magnificent
Sex: The Seven Dimensions of a Vital Sexual Connection”, by Dr.
Lanna Holstein, “I Am Not In the Mood: What Every Woman Should Know
About Improving Her Libido”, by Dr. Judy Reichman and many others
are wonderful starters.
...Again: Don’t get hung up on desire. If you choose
hormone therapy, especially if supplemented with testosterone, this aspect
of your sexuality will improve, but not necessarily dramatically. Remember,
desire and frequency of sex is not as strictly dependent upon age, but
on length of relationship. An “old married couple” of 29-year-olds
who have been together 10-11 years will have sex less often than a couple
of 55-60 who are new lovers. It is okay not to have rampant desire. So
what if it takes longer (“the further from the branch, the sweeter
the fruit...”) It takes him longer too...and gives the Viagra time
Michael P. Goodman, M.D. practices gynecology, perimenopausal medicine,
bone densiometry and sexual medicine at “Caring for Women”
in Davis California. His newest books are “The Midlife Bible—A
Woman’s Survival Guide”, and"MEN-opause: The Book for
MEN", released in 2007. MPG:lh