Your vagina does dry up
It's true that some 68 to 86.5 percent of women have problems with sex after menopause, according to a review of medical studies in the journal Obstetrics & Gynecology, but there are treatments that work. "These are extremely common problems, and unfortunately they're not often addressed by the patients or by the physicians, so we have a lot of very unhappy ladies out there," says Mary Jane Minkin, MD, director of the Sexuality, Intimacy, and Menopause clinic at Yale New Haven Hospital and founder of the women's health website MadameOvary.com. The root of the problem with sex post-menopause? It stems from lack of estrogen, which can wreak havoc on the vagina. "The vaginal walls do become thin, they do become dry, and they do lose a lot of their elasticity," says Lauren Streicher, MD, author of Sex Rx: Hormones, Health, and Your Best Sex Ever, and medical director of the new Northwestern Medicine Center for Sexual Health and Menopause in Chicago. "Between 50 to as high as 70 percent of women experience these changes." You may not notice them unless you're having sex—or try to have sex for the first time in a while. Here's what else your vagina wants to tell you.
You may have to work to make sex pain-free
The vaginal drying many postmenopausal women experience can make friction during sex hurt, and studies show that up to 45 percent of women have painful sex after menopause. But remedies for this problem are as close as the nearest drugstore. The first course of action is an over-the-counter lubricant to ease the friction, but not all lubes are not created equal. "The better lubricants are silicone-based, which are very slippery and last longer than water-based," Dr. Streicher explains. "Replens Silky Smooth is a really good one, and Wet Platinum is another." You could try a home remedy like olive or coconut oil, but they can increase the risk of infection and weaken condoms, which could be an issue for sexually transmitted infection prevention if you're with a new partner. Another option is an over-the-counter vaginal moisturizer, which you would used regularly to increase water content in the skin. If OTC products aren't enough, talk to your doctor about prescription for a local vaginal estrogen. Creams as well as rings or tablets are available. "The amount of estrogen that's absorbed through the vagina is miniscule," Dr. Minkin says. Non-estrogen options are an oral prescription pill called Osphena, a SERM (selective estrogen receptor modulator) that turns on estrogen receptors but does not increase estrogen itself; or a recent FDA approved suppository called Prasterone, which uses the hormone DHEA. Finally, a pain-free laser treatment is available that "restores lubrication and elasticity to the vaginal and vulvar tissues," Dr. Streicher says. She recommends the Mona Lisa laser, but it's not covered by insurance. The FemiLift is another popular CO2 laser. Talk to your doctor to figure out which option is best for you.
Your libido may dip
Lack of estrogen may mean that you have less interest in sex—but there could be other things going on as well. "When a patient comes in telling me she has a significantly decreased libido, which is a complaint I hear four, five, six times a day, the first thing I do address is vaginal discomfort," Dr. Minkin says. After all, if sex hurts, you're not going to feel like having it. "In a protective mechanism, you can develop vaginismus, in which because your body is anticipating pain it shuts down even more," Dr. Streicher says. "The opening of the vagina snaps shut, the pelvic floor muscles contract and have a very high tone, and you have a lot of pain that gets worse and worse and worse." Ouch, who'd feel like having sex in that situation? But once your pain is under control, you may feel your sex drive rev up again. If not, Dr. Minkin says treating patients with testosterone (which also decreases during menopause) can help you get your groove back. Here are some libido-boosting tips.
You can still climax no problem
Interestingly, Dr. Streicher says the lack of estrogen that so impacts the vagina during menopause doesn't necessarily affect a woman's ability to climax. "Orgasm is not estrogen dependent, so women can have a healthy, strong orgasm without any estrogen in their bodies at all," Dr. Streicher says. "But having said that, a lot of women do benefit from local vaginal estrogen because it increases blood flow and lubrication, which can in turn help enhance the ability to have an orgasm." If you're in pain during sex, you're going to have a hard time climaxing, but once that problem is resolved, you may find you're off to the races.
Use it—or you may lose it
You may have heard the expression "use it or lose it" when it comes to sex after menopause, and there is truth to it. "Having sex will increase your pelvic blood flow, and anything that increases your pelvic blood flow is good for moisture," Dr. Minkin says. But according to a survey in the Journal of Sexual Medicine, only 36 percent of women in their fifties have sex at least a few times per month, as do only 29 percent of women in their sixties. In order to get the vaginal benefits of frequent sex, you need to have actual penetration (a toy inserted can work as well) frequently. But, Dr. Streicher says you shouldn't force it if it doesn't feel good. "A lot of women who have dryness and pain are like, 'Okay, if I keep doing this then it's going to get better,' and in fact it gets worse," she says. "The whole 'use it or lose it' thing is only an option if you're having pain-free sex—so first fix it; and then use it."
You may have some body issues—or you may feel more confident
Menopause can trigger new body image issues for some women, which can affect how they feel about sex. "We are in a society that venerates youth," Dr. Minkin says. "When you're going through menopause many women will say, 'Oh, this is the end'"—which of course isn't true!" But for other women, with age comes wisdom and greater confidence. "People aren't as critical of their body parts, especially if you're with a long-term partner—there's a real comfort level," Dr. Streicher says. Plus, you're more experienced, and in tune with your body and how it works. "There are a lot of young women who don't understand their own anatomy," she says. Older women know what they like, and how to ask for it. In a 2016 study, researchers from the University of Pittsburgh found that a number of women aged 45 to 60 were actually more satisfied with sex at midlife, even if they weren't doing it as much, largely because they felt more comfortable in their own skin and were more proactive about discussing their sexual needs. Read Dr. Ruth's tips for boosting confidence and your sex life.
Other medical issues can impact your sex life
Although the hormonal changes that accompany menopause are behind many sexual issues later in life, they aren't the only causes. "When you look at a 50- or 60-year-old, half of these women have some other medical problem—heart disease, cancer, diabetes, multiple sclerosis, depression—so we have all these other medical issues that also impact the ability to have a normal, healthy sexual response," Dr. Streicher says. Your doctor can help tease out any medical conditions that often begin at the same time as menopause that can affect your sex life. Plus, medications for these other issues can contribute to problems in the bedroom. "Some medications can decrease libido," Dr. Minkin says. Find out the surprising postmenopausal health risks.
Encourage old dogs to try new tricks
After celebrating double digit anniversaries, your sex life can get, well, stale. "If you've been with somebody for 30 years you may not be terribly excited about this individual," Dr. Minkin says. "I encourage patients to look with their partner for different sex toys that might spice things up." For some women, this may also mean discovering other ways of having sex besides regular old intercourse. "It's like, 'Okay, now we're going to discover new things—it may be bringing a vibrator or new toy into their relationship, or it may be that there's a lot more oral sex or other kinds of stimulation," Dr. Streicher says. "For a lot of women this is a whole new thing that they've never experienced, and it's a very positive thing." Postmenopausal women who are divorced or widowed often find that a new partner is enough to get their sex drive back into gear, even if they haven't hopped into the sack in years. Here are tips to rekindle the fire and make sex great again.
You may have more privacy—or less
Remember when you had young children and were always worried they'd burst in on you doing the deed? Well, by the time menopause rolls around, that worry is most likely history. "Having more freedom and more privacy really can impact folks," Dr. Minkin says. That said, once the kids head out, elderly parents may be moving in. "There are other stressors that a typical menopausal woman is dealing with: taking care of her mother, her in-laws, and everybody's coming back on their doorstep," she says. "So you have people who are tremendously stressed with no opportunity for privacy!" If situations like this are going on in your life, a sex therapist (as opposed to a sexual medicine doctor) may be able to sort out the psychological issues that are contributing to a lack of interest.
Staying healthy can help you have better sex
Research has shown that people who are healthier have more sex, which makes sense. And although staying fit isn't going to solve hormonal or psychological problems, it can help you be in better physical condition for active pursuits like sex. "The studies very clearly show that if you take a healthy 70-year-old, they are more likely to be having sex than a sick 60-year-old," says Dr. Streicher. "Health does trump age." Eating right and getting enough exercise can ward off disease and help your overall quality of life, including your sex life. Here's what intimate couples do in and out of the bedroom to keep their sex life steamy.