Buffing Up Sex After Menopause

by Rebecca Chalker, Ph.D. ©2011

Sex, Lies, and Menopause

There’s a rumor going around that sex takes a downhill slide or worse, crashes like an Alpine avalanche after menopause.  On the flip side, an equally insidious golden-years myth, heavily promoted by TV ads for erection drugs, portrays post-menopausal women always ready for intercourse whenever her partner drops a pill.  “You can do a double-take on that one,” one woman I know responded. 

Sex therapists and researchers vigorously question these equally unrealistic projections—of a bleak sexual desert or a pharmaceutical Niagra—and have identified a host of realistic strategies for maintaining and enhancing sex after menopause.  

The Sisterhood of the Dry Vagina

By far the most common physical problem that women report in their post-reproductive years is dyspareunia—pain or discomfort after the insertion of fingers or sex toys into the vagina, or especially after intercourse.  Truth be told:  reduced levels of estrogen and progesterone do result in less natural lubrication that can cause scary bleeding, tightening of the vaginal opening, and even—quell horror!—vagina shrinkage, that can make intercourse or use of sex toys something akin to torture.

The Use-It-or-Lose-It Factor:

Many women report that regular sex, either with a partner, through masturbation, or ideally, a combination of the two, definitely helps keep vaginal tissues more supple and moist.  Extended sex play before insertion is always helpful for heightened pleasure, even if discomfort isn’t severe.  And liberal use of a water-soluble lubricant is often enough to make intercourse more comfortable.  Having intercourse after a long time or even after a few weeks break can be exquisitely painful, but don’t think sex is over.  If the pre-menopausal vagina can expand to allow the passage of a baby, trust me, it can certainly stretch to meet the requirements of intercourse, vibrators or dildos later in life.  You just need to work up to it.  Over a few weeks or longer, depending on how dedicated you are, the vaginal opening can be comfortably and safely stretched with Richard and a set of graduated vaginal dilators that are available without a prescription over the internet or at medical supply stores.  These dilators are routinely recommended by doctors for women who have had vaginal surgery, radiation for cancer, or other conditions—and they work!  The vagina is imminently stretchable, you just have to tease it along.  Other options include the liberal application of a lubricant and successively larger vibrators, dildos or even blunt household objects. 

Some women report that a small amount of low-dose estrogen cream (Estrace, Estring, and Vagifem for example), applied at the opening and inside of the vagina prior to intercourse is helpful.  Others apply the cream daily for a few weeks, then twice a week or as needed afterward.  The estrogen in these creams is the same in hormone replacement, but is a much smaller dose, and far less is absorbed into your system, so the risks attributed to hormone replacement are assumed to be greatly reduced.  Warning!  Do not use estrogen creams as a substitute for lubricants.  Hormones are absorbed by the penis and in extreme cases may cause your partner to develop painful breast enlargement.  Alternatively, daily use of Replens®, a non-hormonal over-the-counter lubricant, may provide sufficient relief.1  

Low Libido:  Channeling Desire When You Have the Proverbial Headache

After menopause, many women report that it takes longer to become sufficiently aroused to respond to their partners’ sexual cues and this can be perplexing and quite unsettling to both partners.  Decreased interest in sex may be temporary or long-term and a minority of women report that they experience a total lack of interest in or even a revulsion to sex.  On the other hand, some women find that desire can return just as quickly as it disappeared.  For others, identifying the cause or causes may take time and focused sleuthing.  Kathryn Hall’s wonderful book, “Reclaiming Your Sexual Self:  How You can Bring Desire back Into Your Life,” is a go-to resource for more detailed advice.   

Medications, particularly anti-anxiety drugs like Prozac, Zoloft and other serotonin reuptake inhibitors or SSRIs, are known to decrease or even kill the elusive desire, or interest in sex.  On top of this, lower testosterone, the key promoter of desire in both women and men, can cause interest in sex to plummet.   

If you are taking SSRIs or other drugs, ask your doctor to review all of your medications and discontinue any that are not essential.  For certain pills, taking a “drug holiday” on weekends or for a few days during a vacation, can be helpful if your doctor approves.  Reliable research indicates that the SSRI citalopram (Celexa) has a lower negative impact on desire, so switching to it may be an option.2  If you have a partner, it’s important to talk about lower sexual interest so that he or she does not feel that sexual coolness or aversion is personal.

Preventing Dreaded Leaks

Regardless of age, a sudden loss of urine, especially during sex—even when desire is hot—can make you want to avoid it altogether.  But, again, there are solutions.  The gold-standard for incontinence treatment is pelvic floor muscle exercises, commonly known as “Kegel exercises.” These exercises are named after Dr. Arnold Kegel, whose research popularized them in the 1950s.3   Doing these exercises several times a day over a few weeks, followed by maintenance every few days, may be all that is needed to check surprise leaks. “It’s a common myth is that Kegels don’t work. They do, especially for mild to moderate urine loss,” says Dr. Suzanne Frye, a New York City urologist.  “A lot of women think they don’t work because they are actually doing them incorrectly, pushing the vaginal muscles out instead of contracting them,” she says.  Vaginal continence muscles are the same ones that we use to stop the flow of urine.  

News flash:  the huge plus of well-toned genital muscles is the possibility of having more intense orgasms!  If doing Kegels on your own does not improve continence, a biofeedback program provided by a physical therapist who is trained to treat pelvic floor dysfunction can be very effective in strengthening continence muscles and monitoring progress. (Sometimes biofeedback is covered by insurance.)  This program can be combined with bladder retraining, which helps you hold urine comfortably for longer periods of time.  In addition, several medications are available to control overactive bladders.  Surgery to reposition the bladder is also an option promoted by gynecologic and urologic surgeons, but research has shown that this may not be a permanent fix:  the surgery doesn’t always work, and for some women, leakage, compounded by urgency, may return within a year or two.   

Stress:  Another Thief of Desire

“Stress, either chronic or episodic, can have a serious impact on a relationship,” says Dr. Kathryn Harris.  She notes that “Relationship issues are beyond hormonal and can involve depression, anger, power and control, emotional distance or closeness, the need for personal space and a host of other concerns.  “In the face of these problems, or if your partner wants to have sex more often than you do, then sex can become a chore,” Dr. Harris notes.  A key question to ask yourself is “Why do I want to have sex?”  And the answer may involve what is going on—or not going on—in your relationship and how you feel about yourself.  “The sense that your partner needs sex may seem like just another demand,” Dr. Harris observes.  “Women want to be desired, and are very responsive to those cues.” 

Beyond Hysterectomy

The changes that occur with menopause typically occur gradually and can be addressed as they become a problem.  But after hysterectomy if the ovaries are removed, the changes often occur suddenly and sometimes intensely, but can usually be managed with the temporary use of hormone therapy.  As with menopause, sexual issues associated with hysterectomy may include vaginal dryness, reduced or loss of sexual desire, noticeable changes in time to orgasm, less intense orgasms, loss of the ability to have orgasms, and incontinence.  If sex is a priority for you, a proactive approach can solve or certainly temper these problems.  Regardless of the cause, the solutions for vaginal dryness, reduced desire, changes in sexual response, and urinary leakage noted are the same as for natural menopause.

Strategies for Staying Sexual

In addition to the techniques suggested here, many women use a variety of self-help solutions to enhance their interest in, and comfort during sex.  If intercourse is painful and or male partners don’t get erections readily—a common enough occurrence in men after age 40—consider taking the focus of sex off of intercourse and indulge in the much-heralded pleasures of outercourse, which includes mutual masturbation, use of all kinds of sex toys, and every sexual activity except penis-in-vagina sex. Truth be known:  heightened pleasure and orgasm are often more intense for women and for men  through extended, inventive sexual stimulation that postpones or avoids intercourse altogether.  If orgasm isn’t as reliable as before, why not make pleasure the goal of sex rather than orgasm?  In any event, as sex therapist Jo-Ann Loulan asserts, sex should begin with willingness and end with pleasure, with or without orgasm as the ultimate goal.4   It’s the brain, anyway that’s the chief sex organ, not the genitals, so starting fantasies and hot talk might be key to sexual enhancement.  Many couples report that rewarding sex can be as simple as cuddling, trading sensual massages, sharing fantasies, genital stroking, or watching or reading erotica alone or together.  If the genitals respond to such activities, whether or not they are touched, it’s still sex!

Many sex therapists recommend the use of filmed or written erotica as a reliable route to enhancing desire, and erotic material is now readily available for every taste and interest.  Dr.  Harris recommends watching European films and erotica because “American actresses have so much plastic surgery that we losing realistic role models.  It’s refreshing to see a few lumps and wrinkles that give women’s faces depth and character.”  You might check out the Video Library at Good Vibrations (www.goodvibs.com)

In addition, there is a wealth of sexuality self-help material in books, magazines, and the vast resources of the Internet. My personal favorites are sexual techniques based on the ancient Asian traditions of Tantra and Tao, which take the focus off of the genitals and use ritual, extended sex play and full-body sexual stimulation to create more intense sexual response.  Books and workshops by Margot Anand, and Mantak Chia are particularly popular.  Barbara Carrellas’ recent book, Urban Tantra:  Sacred Sex for the Twenty-first Century, updates these ideas brilliantly.If you have serious disability issues, there are several excellent books on sex and disability, especially The Ultimate Guide to Sex and Disability: For All of Us Who Live with Disabilities, Chronic Pain, and Illness, 5 by Miriam Kaufman, Corey Silverberg and Fran Odette.

Self-pleasure Is It’s Own—Ecstatic—Reward

Masturbation isn’t just a crutch to use in place of partner sex. It is a self-affirming sexual activity and is enormously useful in helping to discover different routes to sexual pleasure.  Up to 40 percent of women report that they masturbate on a regular basis, but this incidence may be lower for older women who may remember being discouraged—or even punished—for masturbating as children, and may still be reluctant to engage in this pleasurable sexual activity.  And BTW:  Ultrasound images have captured male and female fetuses masturbating in the uterus!  These images confirm that masturbation is an innate and entirely normal part of sex!6

Safer Sex: The explicit truth is:  regardless of age, in partner sex, we are all at some risk for contracting a sexually transmitted infection (STI), including HIV/AIDS.  In fact, one in ten people diagnosed with AIDS in the U.S. is over the age of 50 and research shows that, based on habits from the past, people in this age group are reluctant to use protection.  Not surprisingly, transmission rates are much lower among lesbians than among gay men and heterosexuals. Discuss a new partner’s sexual history, keep condoms handy, and don’t take any risks. Outercourse, as described above, greatly reduces the risk of STIs, without reducing pleasure, and is imminently useful regardless of one’s sexual orientation or interests.

Search and Be Rewarded

Websites devoted to sex and aging provide information on every conceivable topic.  Sex diva Betty Dodson, a very youthful 84, is celebrating more than 40 years of helping women explore and enhance their sexuality. Recently, Dodson teamed up with the dynamic Carlin Ross to build a new interactive website that provides resources on a wide array of topics (see: www.dodsonandross.com). Dodson also appears in Still Doing It: The Intimate Lives of Women Over Sixty, a film and book of the same title by Deirdre Fishel and Diana Holtzberg  (see: http://www.stilldoingit.com/ index.html). 

News Flash! Sex Boutiques That Cater to Women

Incorporating sex toys, especially vibrators, into masturbation or partner sex can be extremely helpful in breaking out of boring sexual routines.  The good news is that there are now many bright and engaging sexuality boutiques that cater to women.  Generally these are available in large cities, but all have extensive online and printed catalogs to enable shopping in the privacy of one’s own home. For a start, Babeland (www.babeland.com), Good Vibrations (www.goodvibes.com), and Eve’s Garden (www.evesgarden.com) have especially wide selections.  If it’s out there, they have it! And so can you!

Problem Cases? Sex Therapists to the Rescue

If you’ve tried everything and are still in the sexual doldrums, don’t give up!  Consider seeing a sex therapist who can help you sort through feelings about sexual difficulties, issues with a partner, or medical conditions that impact on sex, and can make additional suggestions about how to cope with any problems you may have.  If you don’t have a direct and reliable recommendation, the best way to find a trained sex therapist in your area is to go to the American Association of Sexuality Educators, Counselors, and Therapists’ website (www.aasect.org).      

Pleasure Is Too Precious to Waste

Sorting out sexual issues can be a daunting proposition, and many of us might prefer to sweep them under the carpet and read a book, finish a report, rake the yard, or paint the bathroom—anything that doesn’t cause such anxiety and frustration.  But clearly solutions are available—so be proactive!  Sexuality and sexual expression are among life’s greatest gifts, and are ours to explore, tweak, enhance, and enjoy, on any level that is possible and comfortable.  Sex is just too precious to waste.  Whether you are solo or with a partner, good sex—by your personal definition—can enhance health, affection, love and self-esteem—and they are not just the province of the young and agile! 


1. Van der Laak, JA, de Bie LM, de Leeuw H, et al, “The Effect of Replens® on Vaginal Cytology in the Treatment of Postmenopausal Atrophy: Cytomorphology Versus Computerised Cytometry,” Journal of Clinical Pathology 2002; 55(6): 446–451.

2. Ferguson, JM, “SSRI Antidepressant Medications: Adverse Effects and Tolerability”, Primary Care Companion, Journal of Clinical Psychiatry 2001; 3(1): 22–27.

 3. See “Kegel Exercises: How to Strengthen Pelvic Floor Muscles” at:  http://www.mayoclinic.com/health/kegel-exercises/WO00119.

4. Loulan JoAnn, Lesbian Sex, Midway, FL: Spinsters Ink, 1984. 

5. Kaufman M, Silverberg C, and F Odette, The Ultimate Guide to Sex and Disability: For All of Us Who Live with Disabilities, Chronic Pain, and Illness, San Francisco:  Cleis Press, 2007.

6. Giorgi G, Siccardi M, “Ultrasonographic Observation of the Female Fetus’ Sexual Behavior in Utero,” American Journal of Obstetrics and Gynecology: 1966;175:753.