They say that 50 is the new 40. What they don't say is that while you might act and feel younger at 50 than your mother did even at 40, your body is still 50 years old. That typically means a significiant drop in estrogen levels. Beyond the hot flashes and night sweats, such a decline can also lead to changes in your sexual function and reproductive system.
As you probably know, sex starts in the brain, not the vagina. And the part of the brain responsible for sexual function and mood—the hypothalamus—is a hotbed of estrogen receptors. That means estrogen, along with testosterone, likely plays a role in your initial desire.
And, it turns out that estrogen is to your vagina what moisturizer is to your face—and more! It's critical for keeping things moist, healthy and flexible down there. The vagina, clitoris, urethra (the tube leading from the outside of your body to the bladder), bladder and other urogenital components all contain significant numbers of estrogen receptors. That means they rely on estrogen for healthy functioning. As estrogen levels decline and less reaches these tissues, they literally atrophy or shrink, not just dry up—sometimes resulting in a significant negative effect on your sex life.
Let's start with the vagina. Without sufficient estrogen, it becomes dry and less acidic, increasing the risk of infection. It takes longer to get lubricated for sex, even if you're ready and full of desire. Over time, estrogen deficiency can lead to more significant changes in the entire urinary/genital area, including reduced blood flow to the vagina, and the tissue itself becomes thin and weak. The result: dryness, irritation and pain upon intercourse, also called dyspareunia.
Estrogen loss also can lead to changes in the size and sensitivity of the vulva, vagina and clitoris, as well as reducing blood flow to these areas.
Estrogen isn't the only hormone you need to worry about, however. Testosterone also plays a role in your sexual desire and satisfaction. Unlike estrogen, testosterone levels don't suddenly plummet at menopause, but, rather, decline gradually beginning in your mid-20s. By the time you reach menopause, your body is producing about half as much as it did when you were in your 20s.
Researchers are still debating testosterone's role in women's sexuality. They think it contributes to blood flow and arousal of the clitoris and labia (the tissue around the vagina) which, in turn, contributes to arousal and orgasm. Hormone receptors are prevalent in the hypothalamus, the part of the brain that controls sexual function and mood. So, it appears that both estrogen and testosterone may influence getting a woman "in the mood."
But the precise role of testosterone in female sexual desire is still being determined. Although most studies confirm that testosterone is strongly related to sexual drive, the correlation between sexual problems and low levels or testosterone is inconsistent (that is, testosterone levels do not predict sexual desire levels). More research is needed to define the significance of testosterone levels in women and what constitutes "normal" testosterone levels in postmenopausal women.
Nonetheless, studies find that women with abnormally low levels of testosterone benefit sexually with supplemental testosterone. We also know that taking oral estrogen could reduce levels of available testosterone by increasing the amount of sex hormone binding globulin (SHBG). Testosterone links up with SHBG, making it useless to sexuality.
These are all issues to consider when you broach the topic of sexual desire and sex with your health care professional. And I definitely recommend it as a topic worth exploring.
That's because there are medical options to counteract the estrogen drop. For instance, topical estrogen in the form of a cream, ring or pill inserted into the vagina can help restore tissue health, flexibility and lubrication to your vagina with few of the side effects known to affect women who take oral estrogen. In fact, studies on these products find extremely high rates of improvement in dyspareunia, with up to 93 percent of women reporting significant improvement and between 57 and 75 percent saying that their sexual comfort was restored, depending on the approach used.
If you'd rather not go the estrogen route, consider using some of the over-the-counter products designed to increase sexual comfort. Long-lasting vaginal moisturizers provide relief from vaginal dryness for up to four days, possibly making intercourse less painful. They have no effect on the underlying cause of vaginal dryness.
If your sexual problems appear related to low testosterone, your doctor may suggest a trial of a topical testosterone gel or even the insertion of a testosterone pellet. Although not FDA-approved for use in women, it is sometimes used "off-label" for this purpose.
On the other end of the spectrum are sexual issues that arise apropos of nothing hormonal or medical; they are simply the result of time and/or relationship issues. For instance, the whole myth about women losing interest in sex around the time of menopause may result from simple boredom. After all, studies find that while the frequency of sex drops by half in the first year of marriage, it takes another 20 years to see such a large drop again—right around middle age. Could it be that women (and men) simply tire of their partners? That sex has become all-too-routine?
One recent study to evaluate sexuality in women pre- and post-menopause is the Women's International Study on Health Sexuality (WISHeS). Researchers mailed a survey to 25,000 U.S. women between the ages of 20 and 70. More than half (14,605) completed it and mailed it back. The study found that between 24 percent and 36 percent of women, whether postmenopausal, surgically postmenopausal or premenoapausal, had low sexual desire. In other words, the lack of sexual interest was not tied to age, but to other problems such as arousal, orgasm or reduced pleasure.
The question about how common sexual function is in women of all ages remains uncertain. The 2008 PRESIDE (Prevalence and Correlates of Female Sexual Disorders and Determinants of Treatment Seeking) trial, a large, national study, reported the overall prevalence of sexual disorders to be 12 percent when including subjects meeting the "distress" criteria for a true diagnosis and over 40 percent for subjects reporting a sexual problem. Other studies of "older" women include reports of "problems" (not necessarily diagnoses) and therefore show rates as high as 43 percent for low desire, 39 percent with poor lubrication and 34 percent with inability to achieve orgasm.
Interestingly, the PRESIDE data indicated that sexual dysfunctions associated with distress were more common between the ages of 45 and 65 (versus both younger and older women). One reason for this may be that older women may have modified expectations about sexual function and can therefore experience greater satisfaction in their sexual lives despite the inevitable consequences of an aging body.
Bottom line: You deserve a dynamic, exciting sex life (if you want it) no matter what your age. By exploring the reasons for changes in your sex life with your partner and your health care professional and taking the necessary steps to resolve any problems, you can have it!
