If you are drinking your morning coffee while reading this, then perhaps this article should come with a warning. There are going to be phrases that we tend not to discuss much in public such as vaginal dryness, loss of libido and erectile dysfunction. However, they are a natural part of life, and if we want to continue to be active sexual people well into middle age and beyond, then we have to acknowledge and then address them, because turning the trials and tribulations of middle-age sex into the joy of sex is not difficult.
Sex is important to all of us, regardless of age. Not only is it excellent for getting the blood pumping and putting a youthful spring in your step, it has a number of other benefits too, such as reducing stress, strengthening your immune system, boosting self-esteem, and relieving depression.
The famous manual, The Joy of Sex, still has some salient advice for middle- aged and older people even though it was written nearly 50 years ago. It's author Alex Comfort wrote: "The things that stop you enjoying sex in an old age are the same things that stop you from riding a bicycle – bad health, thinking it's silly and no bicycle".
Well, we can pump up a flat tyre, add some lubricating oil, and still be having sexual enjoyment with no partner. As recent research has shown, and despite an ageist societal view on the topic, our sexuality doesn’t die with middle and growing age. Our sexual needs and levels evolve and change over the years, and the particular issues that might arise from menopause, for example, do not mean we should give up on it. We just need to learn to adapt.
Emily Power Smith may be Ireland's only clinical sexologist, and talks to large numbers of middle-aged women in her clinics and at talks around the country. "I've spoken and written more on this topic than any other related to sex, and the main driver for women coming to me with an issue is poor education. Generally women are very misinformed about what they should be expecting and are very quick to blame themselves."
If we look at sexual activity as a life-long issue, there can be plenty of interruptions to the normal flow, including illness, childbirth and child rearing, loss of confidence, menopause, and hormonal fluctuations. Low libido, erectile dysfunction, and vaginal dryness are all just normal challenges that can affect our sexual lives, but importantly, ones that can be easily addressed.
"We do specific menopause consultations and counselling for women who start experiencing changes and want to know that they are a normal part of the ageing process," says Dr Shirley McQuade, medical director of the Dublin Well Woman Centre. "Many women come in with a specific symptom thinking it's all over, but in fact nearly all issues can be addressed. You just need to realise that your, and your partner's body changes."
So what are the main issues and what can be done about them?
Menopause can effect every aspect of your being, and symptoms including hot flushes, not sleeping, and poor concentration levels, can affect how you feel about yourself.
“Hormonal changes can mean your libido and sex drive go, as well and the emotional havoc they can play,” explains Dr McQuaid. Mood swings, empty nest syndrome, trying teenagers, or work/life balance can weigh in to make us feel less than energetic about sex.
“It is really important to take the time for yourself when you are peri-menopausal, to take stock and adjust to the changes that are happening. I see lots of women who have reached senior career level or have lots of people depend on them and it can be difficult because they feel overwhelmed and aren’t giving enough time to themselves to deal with how they feel.”
The advice is to take pressure off yourself, and try and cull some of the responsibilities. Exercise, eat and sleep well and acknowledge that you can seek help if you need it. “I’ve seen women go to cardiologists because they think they have heart problems when they wake up sweating in the night, or go to rheumatologists with joint pain, when in fact they are just the symptoms of hormonal change.”
Hormone Replacement Therapy
HRT is a common treatment for women who are suffering from continued and difficult symptoms, and it only takes two or three weeks to find out if it will work for you. According to the National Institute for Health and Care Excellence (NicE) in their 2015 recommendations, the benefits of HRT, available in tablet form, gels, and patches far outweigh any risks.
According to Dr McQuaid, it is a positive option to take. “About 15 years ago there were scares about risks relating to heart disease and cancer, but the studies were seriously flawed. For women who take it through their 50s, the benefits are significant.”
HRT is available for as long as your symptoms last, with the average duration being eight years. Despite scaremongering to the contrary, there are no withdrawal symptoms or problems when you stop taking the drug, as long as you leave it long enough for your natural menopause to conclude. HRT masks the symptoms, so if you stop before they have fully receded, they will return.
Not all women experience menopausal symptoms, and for women who do, they do eventually pass.
It is completely normal for most women in menopause to experience dryness. The drop in your body's oestrogen levels means the vaginal membranes become thinner and drier which can makes for uncomfortable dryness. As a result, thrush and Urinary Tract Infections (UTI) are also more common. Lubrication is widely available and will transform your sexual experience if dryness is a problem. Dr McQuaid also recommends treating the underlying issue rather than just the symptom. A prescription product, licensed in Ireland as Vagifem, provides low levels of oestrogen to the local area, and if taken over the longer term can alleviate all symptoms of dryness. Regular sexual activity or stimulation from masturbation also promotes vaginal health and blood flow.
For men who may identify their every maleness with work and sexual ability, a lowering of libido or erectile dysfunction can be catastrophic. However, accepting that this will happen occasionally, and seeing it a normal part of the ageing process and hormonal changes may encourage them to seek help. The advice is to go to your GP to get checked out to make sure erectile dysfunction is not related to vascular changes and bold pressure / diabetes, and then again there is a simple medication solution.
Again this can be a common change in sexual experience, usually due to vaginal dryness. However, other reasons could be a prolapse of the uterus or front wall of vagina which can cause discomfort, so the first port of call for any pain is to get examined by your GP or at the Well Women clinics. All issues can be addressed with medication or procedures.
A common complaint for women entering peri-menopause is very heavy periods, which are caused by the womb being uncomfortable and bulky. Some women from the age of 40 develop fibroids which make the womb heavier and along with hormonal fluctuations, combine to make structural and hormonal changes that affect the flow of periods. Some women have low iron levels, because heavy periods are the main reason for low iron which makes you tired, so it’s important to keep a medical check on your body while going through the menopause.
Traditionally this was often treated by a hysterectomy, whereas today women can access the pill or coil. All countries where the coil has been introduced have seen a significant reduction in hysterectomy operations.
Change of mind
Addressing specific symptoms is only one way of evolving our sexual lives. Changing the way we have sex is another. “I meet women who have only ever used one position, and now that that proves painful they are at a loss,” explains Dr McQuaid. “It’s useful to experiment and change. It’s more interesting too!”
What we need to remember is that sex is not just about intercourse. There is a variety of sensual, loving, exciting activities that can bring joy and satisfaction. For women experiencing menopause especially, they might need and want more touching and foreplay than before, but after years of marriage, it can be more difficult to change. Asking for what you need is important. Tantric sex – slightly ridiculed in the press after Sting and Trudie Styler admitted to it – is encouraged by many counsellors as it focuses on the sensual intimacy rather than an orgasmic goal.
Whatever the issue with sex may be, Dr McQuaid advises you start with a medical to check to make sure everything is okay. Once that is done, it’s just about dealing with specific issues. “I’ve had a 78-year-old woman come to me recently having a little bit of trouble because her partner has been given Viagra. So she went on Vagifem and has no more problems,” says McQuaid. “I have lots of women come to us for help and they’re happy and healthy and they certainly don’t stop having a sex life. Nor should they.”
Psychologically however, it is also important to rise above the social conditioning that we lose our sexiness as we get older. “There is just no scientific evidence to back this up,” explains Power Smith. “Irish women are very quick to blame themselves and feel guilty for not being better, not feeling enough or good enough. In part we are brought up to feel this way with magazines and media, and then when middle age hits, physical things happen to compound that.” She has three golden rules for women in their middle age with regards to keeping their sex lives healthy and functioning: masturbation, lubrication and communication.
So while the number of potential causes of sexual changes and challenges during menopause and middle ageing can seem overwhelming, there are just as many strategies and treatments for overcoming them.
You can go back to drinking your coffee now.
PANEL: Tips to keep the zest in your relationship as you age?
* Give time and energy to sex. Menopause and other symptoms can make us feel less spontaneous.
* Make good sex a priority. If you’re experiencing a loss of libido, or erectile dysfunction, consider sensual techniques such as Tantric sex, which is not just about physical release but about deepening the sensual experience and emotional connection.
* Make sure you keep yourself as healthy as possible with good exercise, nutritions and rest.
* Do things you enjoy together and have fun together.
* Don’t be afraid of changes to your sexual experience. Talk about how you feel and if you’re having problems with sex, discuss what may be at the root of it.
* Do something about it. Don’t assume great sex happens automatically.