Couples whose sexual relationship has vanished into thin air like so much birthday-candle smoke tend to blame the ravages of time: boredom, menopause, just getting older. But those aren't the real problems.
A 2008 study of more than 40,000 women found that 45 percent experienced sexual dysfunction, compared with 31 percent of men. The peak age for complaints: 45 to 64.
"Impaired sexuality and sexual function aren't normal consequences of aging," says geriatric psychiatrist Ken Robbins, a Caring.com senior medical editor. Adds Elizabeth G. Stewart, an assistant professor of obstetrics, gynecology, and reproductive biology at Harvard Medical School and the author of The V Book, "Sex can be more satisfying than ever during perimenopause and after menopause -- if you avoid certain traps."
Here are seven of the most common sex-stoppers of the 40s and beyond:
Romance Stopper #1: Pain and discomfort
Discomfort during intercourse -- usually vaginal dryness -- is the number-one sexual complaint of women over 40, the years of perimenopause and postmenopause. That's because falling estrogen levels cause the vaginal walls to thin and the usual pH and bacterial balance of the vagina to change (a cascade of changes known, alas, as "atrophy").
Fortunately, it's a problem for which there are many effective, safe treatments today, especially those that replenish estrogen, according to Stewart. "The real problem is the perception out there that estrogen is awful and will give you cancer immediately," she says, referring to popular concerns about the health risks of hormone replacement therapy. "The local options are so safe and release such tiny amounts of estrogen that oncologists even recommend them for women who have breast cancer, because they don't bump systemic estrogen levels."
Solutions: You don't have to take estrogen by mouth. Estrogen-based treatments available by prescription come in the form of creams (such as Premarin cream), a ring inserted for three-month intervals (Estring), and a dissolvable tablet that's inserted in the vagina (Vagifem). You can also try over-the-counter, water-based lubricants (such as KY Jelly, Astroglide) and longer-lasting vaginal moisturizers (such as Replens and Lubrin).
Romance Stopper #2: Using Antidepressants
Studies have variously reported that 30 percent, 50 percent, or even 70 percent of those who take an antidepressant in the drug family known as selective serotonin reuptake inhibitors (SSRIs) experience a dip in desire or trouble achieving climax. Considering that more than 10 percent of all adults take an antidepressant, that's a big problem.
SSRI drugs (such as Prozac, Zoloft, Paxil) raise levels of serotonin, a mood-regulating neurotransmitter, but they also cause a corresponding drop in dopamine, the feel-good hormone crucial to sexual pleasure. Women tend to be slightly more affected than men.
Solutions: Consider stopping the medication with your prescribing doctor's help to see if the sexual side effects clear and you no longer need the antidepressant, says geriatric psychiatrist Ken Robbins of the University of WIsconsin. Or, Stewart suggests trying a "drug holiday" -- skipping a dose or two of a short-acting SSRI -- which can temporarily restore sexual function without causing a depressive crash, although the same sexual effects are apt to recur when you resume the drug. (It's smart to check with your prescribing doctor before trying this.) You may also want to talk to your doctor about switching to a shorter-acting drug, or switching to a non-SSRI antidepressant. For example, bupropion (Wellbutrin) belongs to a different class of medication not linked to sexual side effects.
Romance Stopper #3: Lack of Sleep
It's ironic that you can't have one without the other, since both sex and sleep are activities that take place in bed but not at the same time. But when a stressed-out life interferes with either partner's ability to get a good night's sleep, sex seems to leave the room.
"Lack of sleep or a disrupted sleep-wake cycle causes mood problems, makes you irritable, makes you less patient -- and it's bound to cause friction in a relationship," says Ken Robbins, a clinical professor of psychiatry at the University of Wisconsin.
Common situations leading to a sex-sleep imbalance: a workaholic partner; someone with chronic insomnia; or a partner who spends nights as well as days caring for a baby, a sick child, or an elderly relative.
Solutions: Temporary sleep disturbances affect every household. But when the situation goes on and on, it's important to find creative ways to protect solid zzz's. (Aim for seven to nine hours a night, says the National Sleep Foundation.) For example, in the case of a live-in relative with a sleep-disruptive ailment (such as Alzheimer's disease), look into respite care such as adult daycare services, which can help make the person more tired by nighttime. There are even night respite programs, or -- if you can afford it -- you may need to hire a night-shift nursing aide.
Don't just write off crummy sleep to lifestyle issues. A sleep disorder specialist or an otolaryngologist (ear, nose, and throat doctor) can evaluate you for physical problems, such as sleep apnea or upper airway resistance syndrome (UARS).
Romance Stopper #4: Not Thinking of Your Partner's Problem as a Joint Problem
Men's number-one sexual killjoy is erectile dysfunction (ED), the inability to maintain an erection sufficient for intercourse. More than half of men over age 40 experience this with regularity (defined by doctors as more than 25 percent of the time). ED is almost always rooted in physical problems, such as diabetes or high blood pressure, and the medications used to treat these conditions.
Fortunately, it's a problem for which modern medicine has found many good solutions. But for every guy who's sold on those Viagra commercials is another who doesn't think anything can be done about his problem, or who's too embarrassed to bring it up with his doctor. "That can leave her high and dry," says Stewart. "Even if he considers it his private problem, his partner needs to speak up. Pester him to see a urologist or his regular doctor."
Solutions: Many men don't realize that Viagra is only one cure. The most common, effective treatments for ED include a vacuum pump (a hollow tube placed over the penis to create a vacuum that sends blood into the penis), penile ring (devices used during sex to maintain blood flow), penile implant (a surgical procedure to insert an inflatable device), and drugs -- chiefly sildenafil (Viagra) and tadalafil (Cialis).
Romance Stopper #5: Misunderstanding How Lust Works
When Susan, 52, no longer felt "tingly down there" when she looked at her longtime partner Sal, even though he was still in great shape, she worried something was wrong with her. Sal, after all, could still take one look at Susan's naked body (or, uh, any woman's naked body) and feel like a 16-year-old. Where did her lust go?
Nowhere -- it's still lying there in wait. Sex researchers used to count the stages of sexual activity as arousal, plateau, and orgasm. In recent decades, it's become clear that there's another stage: desire. So now there's loads of talk about the importance of desire -- and corresponding loads of women worry they have a problem because they don't feel it. Except for one thing: For the typical woman, desire actually follows arousal, according to pioneering work by psychiatrist Rosemary Basson. That is, active petting and pillow talk are what stimulate her desire as well as arouse her.
Solutions: Don't label yourself with a problem that doesn't exist. If you don't feel "in the mood" before sex begins, try it anyway. Give it time, and let your partner know that you like and need warm-up time. Leisurely lovemaking that's not necessarily genitally focused foreplay makes a woman feel closer to her mate and turns her on. The old saw is true, Basson says: Men become intimate to have sex; women have sex to become intimate.
Romance Stopper #6: Not Liking to Talk About Sex
"I was raised not to talk about sex, and so my husband and I never did. We just did it," says Maria, a fiftysomething clerk who also takes care of her live-in mother (who has diabetes). "I never felt any need to dissect sex, because Joe never complained and I had no complaints." But lately sex has become painful. She finds it easier to blame stress than to give in to Joe's advances. He's unhappy, she's unhappy -- and their sex life is going nowhere.
"If a couple has never been good at communicating about their sexual needs, then any sexual changes in the menopausal years or after become even harder," Stewart says. "She needs to be able to tell him if she needs more foreplay or more stimulation, or what feels good. Otherwise an ongoing problem gets magnified."
Solutions: It's never too late to get comfortable with your body, and sharing what it likes with your partner. Many men are turned on just thinking or talking about sexual activity. Meanwhile, when it comes to the discussion, some women feel more at ease starting the conversation in bed, others while still fully clothed. Explain exactly what's not working for you in a way that focuses on your needs: Use "I" sentences ("I need more touching here") rather than "you" sentences that point to what your partner is doing wrong ("You're too fast").
Stewart often points patients who need their confidence raised to the Sinclair Institute, a consumer-product group that creates explicit educational materials, such as the Better Sex video series.
Romance Stopper #7: Funky Menopausal Glitches
"Looks like you have lichen sclerosus," Annie's doctor informed her. Annie panicked. She was expecting him to write off her painful intercourse and swan diving sex life to "the change," not to multiple sclerosis?! In fact, the two diseases have absolutely no connection, although their similar names cause people to mix them up. Lichen sclerosus is a fairly common inflammatory skin disorder of the vulva. For unknown reasons, it often strikes around age 50. And that means it also gets mixed up with menopause.
"Menopause itself is not a bad thing that messes up women's sex lives," says Stewart, who also directs the Harvard-Vanguard Vulvovaginal Specialty Service in greater Boston. "But there are some vulvar problems that peak at this time and that, left untreated, can cause sexual problems."
Lichen sclerosus, for example, often causes itching and, if there are tiny cracks in the skin at the vaginal opening, burning during intercourse. Plain old urinary tract infections can also rise around menopause, thanks to prolapse (a sagging bladder or uterus) or falling estrogen that changes the vagina's acid balance.
Solutions: Don't write off bothersome symptoms as natural consequences of the calendar. If something feels wrong, it probably is wrong -- and it can probably get fixed. (Lichen sclerosus, for example, can be treated with a topical steroid cream.)
Sexologists say there's sexual truth to the adage that you're not just getting older, you're getting better -- at least if you avoid the sand traps.
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