By JANE E. BRODY Published: March 30, 2009 NY Times Concern about the safety of hormone replacement has all but obscured one of the most pressing concerns for women of a certain age: the effects of menopause on their sex lives. Many are reluctant to ask their doctors a question uppermost in their minds: “What has happened to my desire for sex and my ability to enjoy it?”
With fully a third of their lives ahead of them, but with little or none of the hormones that fostered what may have been a robust sex life, many postmenopausal women experience diminished or absent sexual desire, difficulty becoming aroused or achieving orgasm, or pain during intercourse caused by menopause-related vaginal changes.
Sometimes the reasons for these problems go beyond hormones. Some women may consider themselves less sexually attractive as their bodies change with age, or they have partners who have lost interest in sex or the ability to perform reliably.
But for most postmenopausal women, hormone-related changes are the primary factors that interfere with sexual satisfaction. My friend Linda, for example, who lives in Pittsburgh, was 52 years old and recently married when her vibrant interest in sex suddenly plummeted, leading to a frantic search for a way to restore it.
A more common situation is described by Pat Wingart and Barbara Kantrowitz in their informative book, “Is It Hot in Here or Is It Me?” (Workman, 2006): “You’re not in the mood a lot of the time. Most nights, you just wish your partner would roll over and go to sleep. When you do feel like a little action, it takes forever to get warmed up. Sometimes sex is more painful than pleasurable.”
Unlike Linda, who had an abrupt change in desire, many women report a gradual decline in sexual desire as they age. In a survey of 580 menopausal women conducted by Siecus, the Sexuality Information and Education Council of the United States, 45 percent reported a decrease in sexual desire after menopause, 37 percent reported no change and 10 percent reported an increase.
Although individual experiences certainly vary, “Changes in arousal clearly are associated with menopause,” according to a 2007 article in The Journal of the American Medical Association. The author, Dr. Jennifer E. Potter of Harvard Medical School and Beth Israel Deaconess Medical Center in Boston, said physical factors include less blood flow to genital organs, a decrease in vaginal lubrication and a decreased response to touch.
Women can achieve orgasm throughout their lives, but they typically need more direct, more intense and longer stimulation of the clitoris to reach a climax, Dr. Potter noted.
Another common experience is a diminished intensity of orgasm and painful uterine contractions after orgasm, although the women surveyed by Siecus said over all that they remained satisfied with sex.
Yet as Dr. Potter put it, “What might be a satisfying sexual life for one woman may seem woefully inadequate to another,” adding that what a woman expects from her sex life can make a difference. She cited the findings of various large surveys: “Only one-third to one-half of women who report decreased desire or response believe they have a problem or feel distress for which they would like help.”
So what happens to a woman’s body when levels of sex hormones fall?
Although estrogen is a woman’s predominant hormone before menopause, testosterone, produced in women primarily by the ovaries and adrenal glands, is considered the libido hormone for both men and women.
Testosterone levels in women decline by about 50 percent between the ages of 20 and 45, and the amount of testosterone produced continues to decline gradually as women age. While menopause itself has no direct effect on testosterone production, surgical removal of the ovaries can cause an abrupt drop in this hormone and accompanying sexual desire, especially for women who have not gone through natural menopause.
For some women, the increased ratio of testosterone to estrogen that occurs after menopause gives their sex drive a boost, Ms. Wingart and Ms. Kantrowitz point out.
But for most women, the menopausal effects of low levels of estrogen are the primary deterrents to sexual pleasure. In addition to the infamous hot flashes, changes in the vagina and vulva can have serious effects on the sexual experience.
With little or no estrogen, vaginal walls become dry, thin and less elastic, causing pain during penetration.
Diminished blood flow to the genital area means it can take much longer for a woman to feel aroused.
The anticipation of painful uterine contractions with orgasm can be a turnoff.
A leakage of urine some women experience during sex can prompt them to avoid it.
Linda, who asked that her last name not be used, said she was more concerned about reviving her sex life than a possible increased risk of hormone-induced cancer or heart disease. A prescription of the drug Estratest, which combines estrogen and testosterone, solved her problem.
But taking estrogen orally is not recommended for women who have had breast cancer or are at high risk for developing it. Also, to protect the uterus against cancer, estrogen should be combined with a progestin.
An alternative that works for some is vaginal application of a little estrogen via a cream, ring or tablet, which keeps the hormone from passing through the liver and diminishes the amount that enters the bloodstream.
Gynecologists concerned about safety are more likely to recommend a non-oil-based lubricant. Besides such popular products as K-Y jelly, Ms. Wingart and Ms. Kantrowitz suggest several longer-lasting products that have an adhesive quality, including Replens, K-Y Long-Lasting Vaginal Moisturizer and Astroglide Silken Secret. The authors said “women who have intercourse regularly seem to generate more lubrication than those who do it less frequently.”
Infrequent intercourse or prolonged periods without it can result in a narrowing of the vagina that can be countered by the use of lubricated vaginal dilators. For women whose sex lives are disrupted by lack of a partner, the authors recommend self-stimulation. Dr. Potter suggested that even for women with partners, a vibrator or small battery-powered vacuum pump can aid in arousal.
While a Viagra-like drug is not yet an option for women, use of the antidepressant bupropion (Wellbutrin at 300 milligrams a day) may improve sexual arousal and satisfaction in women who are not depressed. And Dr. Potter pointed out that remaining physically fit can also help