MBChB (UP); MHSc: Sexual Health (US, Aus); FECSM (Fellow of the European Committee for Sexual Medicine)
Sex after the age of fifty is not unlike cycling after fifty. There are reasons why people stop doing it, take it up for the first time, enjoy it more than ever and have real physical and psychological challenges with it.
It can be very difficult to raise the subject of sexual activity with any patient, let alone an “older person”. Not that fifty is old. Life expectancy is between seventy and eighty years in most first world countries and still around sixty years in South Africa, despite all our public health issues.1
People form new relationships after the age of fifty or have the chance to really start enjoying their lifelong partnerships because other stressors like raising kids together and building a career are not so prominent anymore. Latest research shows a third of women and half of men remain sexually active after the age of seventy2 and that people participate in a wide range of practices when it comes to solo or partnered sex.3
Getting into Gear:
Unfortunately only 6% of doctors talk to patients about their sexual functioning and the most common reason stated for not taking to patients about it, is their age.4
Due to the sensitive nature of this subject, it is the responsibility of the clinician to initiate the conversation. It is not that difficult when you follow a rehearsed script. Here is a suggestion:
“Women over the age of fifty, often have problems with their sexual functioning, how about you?”
This statement and question gives the patient PERMISSION to talk to you about her sexual challenges. It is the first step in the PLISSIT Model5, followed when we deal with patients with sexual health questions and challenges. The second step is LIMITED INFORMATION and the third is SPECIFIC SUGGESTIONS. Only the last step is Intensive Therapy. As you get more comfortable talking to patients about their sexual concerns, you will realise that there is only a small percentage of patients who need intensive therapy. Most are helped with limited information and specific suggestions.
But how do you have the rest of the dreaded conversation?
When people talk to kids about sex, they tend to feel more uncomfortable than the kids themselves and end up using metaphors and strange euphemisms. One has to be careful not to sound patronising when speaking to older people about sex, but using a metaphor can make it easier for both the patient and the clinician.
I have found that the cycling metaphor goes a long way in delivering that basic information and those specific suggestions in a way that is comfortable, clear and practical for the patient. You start by using the word “they” and not “you” and then the patient can personalise it if they want to. This technique helps you not to make any assumptions but to give the patient the opportunity to put her concerns, fears, challenges and questions into words.
If the woman has a specific complaint like vaginal dryness, you might be able to treat it without having to go into detail. If however she says: “Well doctor, we have not had sex in more than a year and I don’t know why” and you feel like rolling your eyes and checking the clock, rather have this five minute limited-information-specific-suggestion-session with the patient:
You can say:
“The reasons why people don’t have sex as the get older are more or less the same as why they don’t ride bicycles anymore. Let’s go through a few of them and you can tell me which ones, if any, you relate with:”
1. They think they are too old and will look or feel stupid.
If you look at the following graph, it shows that many people remain sexually active till very late in life. It might not look like and feel like Hollywood and there are some changes and challenges, but you are never just too old for it.
Graph 1: Percentage of American Performing Certain Sexual Behaviours in the Past Year3
The best is to never stop cycling and if you have to due to injury or unforeseen circumstances, get back onto your bike as soon as possible.
If people continue to have sex at relative regular intervals, it never becomes a big issue. If you have not done it in a long time, it is like getting back on a bike – you are a bit tentative and not sure if you still have that muscle memory to know how. So how do you do it? You don’t get on that bike and try to do a three day endurance event. You try in the driveway first, keeping your feet close to the ground, going slowly, not aiming for distance or speed, just the satisfaction to know that you still can. When you get the thrill of getting it right, even if it is just balancing your way down a slight slope, you realise that you are creating a special experience. Not a masterpiece. Not a new record with the greatest of speed in the shortest of time, but something special and enjoyable. You don’t even have to reach the finish line to have fun. A leisurely ride in the park can be much nicer than a high profile race.
This kind of explanation is particularly valuable when talking to patients who are struggling with their sexuality due to breast cancer or other disfiguring medical conditions. It does not have to be perfect to be good. Refer these patients for “intensive therapy” if your initial reassurance is not enough.
2. They don’t have the physical ability anymore:
Medical conditions and medication used have a significant impact on a post-menopausal woman’s sexual functioning.2
Menopause is associated not only with decreased desire but also with the physical aspects of sexual response like arousal and orgasm2. This can partially be due to a decline in free testosterone which is best correlated with increasing age, not necessarily menopause itself.6 The right hormone replacement therapy (HRT) can improve a women’s sexual functioning7 and can include transdermal testosterone therapy in women with low serum levels and a formal diagnosis of sexual interest/arousal disorder (formerly known as hypoactive sexual desire disorder).6
Dyspareunia is also one of the symptoms of the newly described Genitourinary Syndrome of Menopause and can be treated or avoided in most cases by the simple use of topical oestrogen therapy.8 It is no longer available over the counter. Make sure you offer it to your symptomatic post-menopausal patients. Hysterectomy and other pelvic surgeries can also contribute to dyspareunia in this age group.9
Many women in menopause end up using antidepressants drugs. The depression itself as well as the medication can cause sexual dysfunction and patients need to be monitored for this. Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin Nor-Adrenalin Reuptake Inhibitors (SNRIs) are the biggest culprits and Bupropion seem to be beneficial on its own or if used as an antidote to treat the sexual side-effects of other drugs.10 Polypharmacy is quite common in postmenopausal women and can contribute to sexual dysfunction. Try to change the medication to drugs with fever sexual side-effects.
PAIN & WEAKNESS:
Pain and weakness often play a role in making sex practically difficult. Being willing to listen to the patient’s actual challenge and providing practical solutions will go a long way in helping most patients. Take painkillers an hour before sex, use a position where there is less strain on the hips for instance, like lying on your side and using a rear-entry approach.
As with cycling, it might be necessary to do some preparatory training to before you get back on the proverbial bike again. Vaginal dilators and physiotherapy are often used in conjunction with topical oestrogen if there has been significant atrophy and especially if vaginismus has developed11. Sensate Focus exercises are also used to help a couple to gradually restore intimacy in their relationship. Sex is initially forbidden and sexual massage that gradually becomes more stimulating is practiced over a few weeks to re-establish physical and emotional intimacy.12
3. Their Bicycle is Broken:
Having a partner who suffers from sexual dysfunction is very common in menopausal women. The woman might still be willing and able, but the partner has developed erectile dysfunction (ED) and therefore intimacy stops all together. You don’t have to have the latest model in perfect working order to have a fun ride in the park and likewise you don’t need perfect performance to have a special experience with your partner. Unfortunately men tend to withdraw from intimacy if they can’t trust their performance anymore. This often leaves women feeling not only physically unfulfilled but emotionally neglected and often induces sexual dysfunction in her.13
Men generally have very poor help-seeking behaviour and when it comes to their sexual performance, they are even less willing to consult their GPs. When a man’s sexual interest and ability starts to dwindle, it can be an early warning sign of cardiovascular disease. For this reason we cannot just give a women a prescription for a PDE5-inhibitor for her husband. He needs to have at least his blood pressure, abdominal circumference, fasting glucose, lipogram and early morning testosterone measured with possible cardiologist referral if significant cardiovascular risk exists.14
That said, we don’t need to be overly cautious when prescribing PDE5-inhibitors to men with erectile dysfunction. It is generally safe and should just not be combined with nitrates, but men with high blood pressure, diabetes and hyperlipidaemia can safely use it.14,15
Using vacuum pumps and injectables are also options. These have to be prescribed with the necessary education and support, but once patients learn how to use it, it is generally well accepted.15
4. They don’t have a Bicycle:
Of course many women over fifty don’t have partners anymore. If you are not sure about this, you might want to start with this one.
Forming new partnerships later in life is common and it can be very rewarding. It can also be daunting! The fact it that it is not merely buying a new bicycle, it is much more serious than that!
Women might also start to have more informal relationships for the first time in their lives. Basically all potential partners that they meet at this age, will have previous sexual experiences and therefore they are at increased risk to pick up a sexually transmitted infection. They don’t think so, but they are! Condom use is very poor in this age group and it gets worse as they age.3 Some counselling about safe sex is definitely necessary in this age group. Use the cycling metaphor again: you hardly ever see people cycle without helmets on anymore. The benefits are well-known and therefor it is frowned upon not to use a helmet. The same goes for sex. Safety first. Make sure you are using a condom. Does not matter how nice, wealthy, respectable or “clean” he looks.
Also note that you should not assume that a woman is having sex with men or only with men. Rather ask and use the word “partner” to be more inclusive.
5. They have fallen too hard before:
Many women have serious psychological damage due to bad previous sexual experiences. Secondary vaginismus is not uncommon in this age group.16 Many will be very happy to decrease and even stop sexual activity as their partner’s needs and ability decreases or if they lose their partners. There are however those who desire to have normal sexual functioning but are held back by psychological issues. Refer these people to well qualified and experienced clinical sexologists who can address those psychological aspects to help her to gradually “get back on the road’ again.
The home stretch:
It is not so difficult to talk to people over the age of fifty about sex. Like cycling, give it a go!
You might change her and/or her partner’s life forever. Remember: 100 orgasms per year can add eight years to a patient’s life – this is serious medicine!17
1. Mayosi BM, Lawn JE, Van Niekerk A, Bradshaw D, Karim SSA, Coovadia HM [Internet]. Health in South Africa: changes and challenges since 2009. The Lancet: Elsevier Ltd; [updated 2012 November 30]. Available from: http://dx.doi.org/10.1016/S0140-6736(12)61814-5
2. Lee DM, Nazroo J, O’Connor DB, Blake M, Pendleton N. Sexual Health and Well-being Among Older Men and Women in England: Findings from the English Longitudinal Study of Ageing. Springer: Arch Sex Behav; [updated 2014 Dec 11; cited 2015 Jan 27]. Available from: http://link.springer.com/article/10.1007/s10508-014-0465-1
3. Herbenick D, Reece M, Schick V, Sanders SA, Dodge B, Fortenberry JD. Sexual Behaviour in the United States: Results from a national probability sample of men and women ages 14-94. J Sex Med. 2010;7 (suppl 5):255-265.
4. Deyer K, Das Nair R. Why don’t Healthcare Providers Talk about Sex? A systemic review of qualitative studies conducted in the United Kingdon. J Sex Med. 2013; 10: 2658-2670
5. Annon JS. PLISSIT Model: A Proposed Conceptual Scheme for the Behavioural Treatment of Sexual Problems. J Sex Ed and Therapy. 1976. Vol 2, nr 1. 10.1080/01614576.1976.11074483
6. Wierman ME1, Arlt W, Basson R, Davis SR, Miller KK, Murad MH, Rosner W, Santoro N. Androgen therapy in women: a reappraisal: an Endocrine Society clinical practice guideline.J Clin Endocrinol Metab. 2014 Oct;99(10):3489-510. doi: 10.1210/jc.2014-2260.
7. Nastri CO1, Lara LA, Ferriani RA, Rosa-E-Silva AC, Figueiredo JB, Martins WP. Hormone therapy for sexual function in perimenopausal and postmenopausal women. Cochrane Database Syst Rev. 2013 Jun 5;6:CD009672. doi: 10.1002/14651858.CD009672.pub2.
8. Portman DJ, Gass MLS. Genitourinary Syndrome of Menopause: New Terminology for Vaginal Atrophy from the International Society for the Study of Women’s Sexual Health and the North American Menopause Society. Menopause. 2014; Vol 21, nr 10.
9. Clarke-Pearson DL, Geller EJ. Complications of hysterectomy. Obstet Gynecol. 2013 Mar;121(3):654-73. doi: 10.1097/AOG.0b013e3182841594.
10. Clayton AH, El Haddad S, Iluonakhamhe JP, Ponce Martinez C, Schuck AE. Sexual dysfunction associated with major depressive disorder and antidepressant treatment. Expert Opin Drug Saf. 2014 Oct;13(10):1361-74. doi: 10.1517/14740338.2014.951324. Epub 2014 Aug 22.
11. Int Urogynecol J. 2014 Dec;25(12):1613-20. doi: 10.1007/s00192-014-2421-y. Epub 2014 Jun Understanding and treating vaginismus: a multimodal approach. Pacik PT1.
13. The Association Between Female Sexual Dysfunction and the Husband’s Erectile Dysfunction: Evidence from Married Couples in Hong Kong. Zhang H, Fan S, Yip P.J Sex Marital Ther. 2014 Dec 16:1-9. [Epub ahead of print] PMID: 25514566
14. Nehra A et al. The Princeton III Consensus Recommendations for the Management of Erectile Dysfunction and Cardiovascular Disease. Mayo Clin Proc. Aug 2012: 87(8):766-778
15. Hackett G. et al. British Society for Sexual Medicine guidelines on the Management of Erectile Dysfunction. J Sex Med 2008:5:1841-65
16. Vaginismus in peri- and postmenopausal women: a pragmatic approach for general practitioners and gynaecologists. Hope ME, Farmer L, McAllister KF, Cumming GP.Menopause Int. 2010 Jun;16(2):68-73. doi: 10.1258/mi.2010.010016. Review. PMID 20729498
17. 100 orgams add 8 years to life