The benefits and challenges of post-menopausal sex
“To many women the menopause marks the end of their useful life. They see as the onset of the end, the beginning of old age. They may be right. Having outlived their ovaries, they may have outlived their usefulness as human beings. The remaining years may just be marking time until they follow their glands into oblivion.” Everything You Always Wanted to Know About Sex (But Were Afraid to Ask), by David Reuben, MD
I hope this outrageous paragraph makes you laugh instead of getting you upset. For my wife Lilith Blackwell and I, it has become a family joke. We thought it would be a good way to start this article because it shows how misogyny and ageism combine to marginalize older women. It seems to be built on one of the nastiest ideas of the Patriarchy: that women are only valuable inasmuch as they serve a reproductive function.
Reproductive success consists of having lots of offspring who live long enough to have lots of offspring. This last part is crucial for humans because it takes a lot of effort to get a child to survive to reproductive age. In turn, that requires strong social bonds in the tribe. In humans, sex evolved away from its strictly reproductive function to become a way to form those bonds. In my article, The Seven Enigmas of Sex, I argue that this explains some strange quirks of human sexuality, like hidden ovulation, orgasms, sexual shame and kinks.
Menopause is uniquely human
One of these quirks is menopause. Unlike what Dr. Reuben says in the quote above, it does not represent the end of the useful life of a woman. It does not even represent the end of her sexual life. Since sex serves primarily to establish a social bond in humans, it is natural for women to continue to have sex after menopause, just like it is natural for them to have sex when they are not ovulating.
Contrary to was first believed, menopause does not represent the gradual deterioration of a woman’s reproductive ability caused by aging. This is what happens in most mammals, but in women it is different. They have menopause, which consists of a cessation of menstrual periods that occurs relatively quickly, on average between 49 and 52 years old. At the same time, there is a decrease in the secretion of female hormones (estrogen and progesterone) by the ovaries. This decrease starts well before menopause, during perimenopause, when women start experiencing symptoms like hot flashes and mood swings. In some women, they may persist after menopause. Other mammals do not have menopause, except for some species of toothed whales. As female mammals age, their estrous cycles become more irregular and frequent, but they do not stop like it happens in women.
According to the grandmother hypothesis, menopause is a specific physiological mechanism that evolved so that women could stop having children and devote their energy to taking care of their grandchildren. Since human children are labor-intensive, taking 12 to 16 years to reach sexual maturity, the best evolutionary strategy for reproductive success is not to have many children, but to ensure that the ones you have reach adulthood and have their own offspring. Therefore, menopause doesn’t happen because a woman should be already dead. Instead, is a mechanism that prepares a woman for another function in the last period of her life: to serve as a repository of the knowledge of the tribe, to become a teacher, healer and helper of younger women and men.
Most women remain sexually active after menopause
In men, sexual desire and arousal are driven by testosterone. When it declines with age, so does male sexual desire. In women, things are much more complicated. Desire is controlled by the female sexual hormones, estrogen and progesterone, but especially by testosterone. Yes, even though testosterone is considered the male sex hormone, women also produce it in lesser amounts. Because of that, even when estrogen and progesterone decline with menopause, many women experience the same or even higher sexual desire. For example, read this article by @Vicki Larson, an expert on the sexuality of mature women, or the articles by @MonalisaSmiled about how her high libido pushes her to have extramarital affairs.
In our society, sexual repression, misogyny and ageism combine in a toxic mixture to attack any expression of sexual desire in aging women. The body of an old woman is derided as utterly undesirable, much more so than the body of an old man. And yet, older women can be sexy and beautiful. Their experience and lack of inhibition in bed can lead to amazing lovemaking. We need to do some serious pushback against the societal de-sexualizing of older women.
Giving up sex is a legitimate option
Still, for many women, sexual desire decreases - or even completely disappears - after menopause. They may find certain bodies beautiful, just not in a sexual way. They also feel less desire to have sex and to masturbate.
You are single. Why bother going into the dating scene when you know it would be frustrating, time consuming and possibly unpleasant?
Your partner has also lost sexual desire. Sexless marriages or romantic relationships - called “companionships” - are enriching and satisfying for many. While it is true that sex provides a strong emotional bond, maybe you and your beloved are already bonded. Human touch is a biological and psychological need, but it doesn’t need to be sexual. Kissing, hugging and cuddling can keep alive the romance.
What is not ethical is to impose chastity on somebody who still wants a sex life. Sexual exclusivity in monogamy is predicated on each partner providing sexual satisfaction to each other. But that doesn’t mean that if one partner gives up sex, the other is obliged to do the same. The right thing to do in that case would be to switch to ethical non-monogamy. This is still frowned upon by society, and this repressive view can lead to the breakup of perfectly good relationships, cheating, or plain garden-variety unhappiness.
It is important to note that low libido can be a symptom of depression or other health issues. It may also indicate that there are problems in your relationship.
Powering through waning desire
However, there are many good reasons to continue to have a sex life, even without strong sexual desire. For example:
Your sexuality is an important part of your life and your self-image, so you might miss it even if you no longer feel sexual desire.
Sex keeps you healthy by making your body secrete estrogen, testosterone, oxytocin, endorphins, adrenaline and other good stuff that promotes bonding and happiness.
Sex is great exercise, increasing your heart rate and keeping your pelvic floor strong.
You love your partner and want to continue to satisfy him (or her) sexually.
Sex makes you feel beautiful and young. It is great to feel desired.
For these reasons, you may want to continue to have sex, even when you don’t feel the fire in your loins anymore.
You can encourage your sexual desire by watching pornography. Alternately, erotic and romantic literature work better for a majority of women. Others swear by audio-porn: recordings of a man with a sexy voice talking dirty to you. Of course, in women of all ages it helps to remove the physical and emotional barriers that sap their sexual energy, like stress, an excessive workload and relationship problems.
The technical name for low libido in women is ‘Hypoactive sexual desire disorder’ (HSDD), and is defined as the persistent absence of sexual thoughts or fantasies and lack of desire for sex that is associated with distress and cannot be attributed to medication or a medical problem (Kingsberg and Simon, 2020). There are attempts to develop medication to treat HSDD.
Flibanserin (sold as Addyi) is a mixed agonist / antagonist of serotonin receptors that was initially developed as an antidepressant (Simon et al., 2018). However, it has been widely attacked in the media for its disappointing efficacy and many side-effects dizziness, somnolence, insomnia and nausea.
Bremelanotide (sold as Vyleesi) is an agonist of the subtype 4 of melanocortin receptors (Pfaus et al., 2021), which release of dopamine in the medial preoptic area of the hypothalamus. A clinical trial (Kingsberg et al., 2019) found that it increased sexual desire.
Testosterone increases the libido of women, just like it does in men, but at much lower concentrations. It increased sexual desire, arousal, pleasure and orgasm in women, with few masculinizing side-effects (Pinkerton et al., 2021). Its use to treat HSDD was approved by an international panel of experts (Davis et al., 2019). However, it is still unknown if it has long-term effects on the cardiovascular system, cognition and cancer.
Feeling sexual desire is not a prerequisite for sex. Desire (feeling horny) and arousal (getting turned on) are independent of each other, even though we may feel that if we are not horny we cannot get turned on. It is possible to get turned on by simply starting to have sex. A low libido does not prevent you from getting sexually aroused, experience pleasure and have orgasms. It's just a matter of getting started. And then, in retrospect, you will be glad that you had sex. Based on that, you can construct a rational sexual desire in which you don't feel the same need to fuck as when you were young, but you know it will be nice, and you anticipate the pleasure and connection that you will feel.
Lube is your new best friend
However, all that is predicated on sex being pleasurable. The ugly reality, for many post-menopausal women, is that intercourse becomes painful.
Though good sex does not require penetration, a large majority of women (69.9%) find vaginal intercourse “very appealing”, almost the same percentage as men (71.3%) (Herbenick et al., 2017). The majority of women interviewed for that paper (52.6%, men 52.1%) had vaginal intercourse during the last month. In another study (Herbenick et al., 2018) that included both pre-menopausal (53%) and post-menopausal (45%) women, 51.8% of them had orgasms at least half of the time with vaginal intercourse. Therefore, the majority of women prefer vaginal intercourse for sexual satisfaction.
One reason why intercourse is painful is the lack of natural lubrication. Women secrete this ‘egg white cervical mucus’ through the Bartholin’s glans, located around the entrance of the vagina, and also from the vagina itself. However, lack of estrogen after menopause causes a substantial decrease in these secretions.
The solution is easy: use personal lubricant. There is vast market for lubes, with lots of choices. Of course, you must avoid products that cause allergies to any of the partners. It’s also a good idea to screen for parabens and other toxic chemicals. If you use silicon sex toys or condoms, use only water-based lubes.
Vaginal estrogen to avoid painful penetration
However, lube was not enough for my wife. Vaginal intercourse was always her favorite form of sex, but after menopause, penetration became increasingly painful. Half an inch in, she’d cry out in pain and ask me to stop and wait. After a while, the pain would go away and we could continue. The anticipation of pain made sex unattractive for her.
Hormone replacement therapy (HRT) can be a solution. It consists of taking estrogens and progestogens, sometimes with the addition of testosterone. Progesterone prevents the endometrial thickening and risk of cancer produced by estrogen. Although the benefits of HRT vary between women, they include reduced mortality in the first 10 years after menopause, with reduced coronary disease, osteoporosis and dementia (Lobo, 2017). However, the first results of the Women’s Health Initiative (WHI) in 2002 “showed that HRT had more detrimental than beneficial effects” (Cagnacci and Venier, 2019), causing a drop in its use. Still, the WHI showed that HRT has beneficial cardiovascular effect in early menopausal women.
Vaginal estrogen could be used to treat vaginal pain during intercourse. Lack of estrogen after menopause causes the vaginal walls to thin, making them sensitive to pain. The same happened to the walls of the urethra, explaining why postmenopausal women have more urinary tract infections (UTIs). Vaginal creams and suppositories delivering estradiol have only a local effect, avoiding the side-effects of HRT.
My wife consulted with her doctor, who gave her a prescription for Imvexxy, a vaginal insert containing 10 micrograms of estradiol. However, Imvexxy is not cheap. A full treatment requires daily insertions for two weeks and a bi-weekly insertion thereafter, which adds up to hundreds of dollars, even with insurance. At first, our insurance refused to pay for it. A less expensive treatment can be achieved using generic formulations. For example, generic estradiol cream costs $74 at CVS. My wife didn’t like the idea of using over-the-counter medications for this purpose, however, and she finally managed to convince health insurance to pay for part of her treatments. One of the “benefits” of the private healthcare system of the United States is to put your sex life in the hands of complete strangers whose main concern is profit.
The treatment was worth the fight, however. By the end of the second week of daily applications, pain with intercourse was almost completely gone. My wife was dancing around the bedroom chanting, “It didn’t hurt! It didn’t hurt!”
Sex on a schedule
Hopefully, vaginal estradiol will also help with UTIs, which are another major concern for my wife and many other post-menopausal women. To prevent them, my wife’s physician prescribed a prophylactic dose of antibiotic before sex. My wife also takes D-mannose and drinks lots of water beforehand so she can pee after sex. We both shower and clean our genitals with chlorhexidine, a non-irritant antiseptic.
Since sex requires so much preparation, it no longer can be spontaneous. That is okay. We became used to sex-on-schedule since our daughter started school. Most mothers find that caring for an infant makes your libido plummet. It also feels weird to have sex with a child in the house who may require your attention at any moment. And you have to keep quiet. When our girl started first grade, I stayed home from work in the morning, once a week, so we could have some private time while she was at school. It worked much better than we expected. Making love, as it turned out, can be great when you anticipate it and can turn your attention away from your child. Scheduled intimacy also provides a stage for the cuddling and conversation that reinforce bonding and counters the stress of everyday life. Even now, some 15 years later, we continue our weekly schedule.
When a woman is young, sex can be an imperious need driving a large part of her life. As she matures, desire may wane, but the quality of sex improves as she gains more experience. When menopause kicks in, sex becomes more and more challenging, but still can be worth fighting for. One of the frontiers of sex-positive culture is to fight against the de-sexualization of older people, especially women. Sex is one of the great joys of life. It helps us stay healthy and keep our bodies from aging. It deserves attention and a bit of work.
This article was written with lots of input, help and love from my wife.