Chapter 37
Sex and Intimacy — Part 2
Although women are less sexually active than men at all ages and masturbate less frequently, they have less of a reduction in sexual desire, frequency and ability to become aroused than men do over time. The explanation for this is not clear but may be related to erectile dysfunction in men. Moreover, difficulties with sexual arousal, orgasm, dry vagina and pain decline among sexually active women aged 80 to 90 years. This may reflect the fact that the healthiest women and the healthiest partners survive into their eighties and nineties or that sexual activity sustains sexual ability. The work of the influential Californian epidemiologist Elizabeth Barrett- Connor and her group first reported that during the menopause, women experience an increase in sexual desire followed by a decline in sexual desire, responsivity and frequency of sexual activities post menopause. However, sexuality does not disappear – it is just less apparent. The decline in frequency of sexual intercourse for women is due to lower levels of oestrogen and testosterone. Oestrogen is produced by the ovaries. As the ovaries begin to die, oestrogen levels drop. This results in a dry vagina, wasting of the labia, vulva and clitoris and thinness of the bladder wall, which causes pain during intercourse. Urinary infections after intercourse also become more frequent. Symptoms of cystitis and urinary tract infections include painful intercourse, pain passing urine, itching in the vulval area, more frequent urination, and sometimes incontinence of urine. Urinary incontinence and cystitis respond to antibiotic treatment, coupled with hormone replacement therapy or oestrogen vaginal pessaries. Sometimes, further medications, such as amitryptyline or pentosan polysulfate may help cystitis if other interventions are insufficient. For prevention, drinking cranberry juice reduces the risk of urinary infections. Regular sexual activity also helps to prevent symptoms because sexual intercourse improves blood circulation to the vagina, which maintains vaginal tissue. Decline in sexual desire can impact women’s self-esteem and quality of life and sometimes cause emotional distress leading to relationship problems. So, treatment that mitigates these unpleasant symptoms described above is important. People are often embarrassed to engage in discussion about sex ‘after a certain age’. But don’t be – physicians aren’t, and will and can help. Because women live longer, there is a shortage of single male partners in the same age group. But hope springs eternal and emanates from the Germans, where a study of single women reported attitudes to and experiences of unconventional sexual relationships in older women. For 91 women born between 1895 and 1936, 1 in 6 of the interviewees had had a relationship with a man younger than themselves, 4 per cent had had a lesbian relationship and 1 in 12 had had an affair with a married man in later life.
Chapter 10: Sex and Intimacy
Most studies of sexual activity in later years traditionally focused on sexual dysfunction or disorders and treatments for same. However, this approach is thankfully changing and there is a global interest emerging in sexual activity, health and well-being. One large study in California looked at sexual activity and sexual satisfaction in 1,300 healthy women aged 40 to 100 years. These well-educated upper-middle-class women, average age 67 years, grew increasingly satisfied with their sex lives after they turned 40. The average period since menopause for women in the study was 25 years. Overall, two thirds of sexually active women were moderately or very satisfied with their sex life. Half reported sexual activity within the past month. For some, that heightened satisfaction came from having good sex; for others, it stemmed from the fact that they had less desire for sex and therefore lower expectations. Most were able to become aroused, maintain lubrication and achieve orgasm during sex, even after the age of 80. In fact, many were completely satisfied over the age of 80. A number of women who weren’t sexually active still expressed satisfaction with their sex lives – indicating the role of intimacy and fondling in sexual satisfaction.
Chapter 10: Sex and Intimacy
So, why do some women become more satisfied with their sex lives as they age? There are several possible explanations: older women are more sexually experienced and more at ease with sex; those older women who are not sexually active achieve sexual satisfaction through other intimacies such as touching and caressing, or some older women who have no intimate contact of any kind are perfectly happy without it. In contrast to younger people, older women were not thinking about sex, planning sex ahead of time or longing for sex during periods of the day but they did have sex that was satisfactory to them. These data suggest that if you hang in there, there’s a good and satisfying sexual relationship for a lot of us up to the end.
Sexual activity in older age is more important for men than women. Eighty-five per cent of men in the UK aged 60–69 are sexually active, as are 60 per cent of those aged 70–79 and 32 per cent of those aged 80 and over. Studies in the US report similar levels of sexual activity across these age groups. Among sexually active men, sex twice a month or more frequently and regular kissing, petting or fondling were associated with greater enjoyment of life.
Chapter 10: Sex and Intimacy
The principal sexual problem that men complain of is erectile dysfunction (ED). ED is the inability to get or keep an erection firm enough to have sexual intercourse. It’s sometimes referred to as impotence, although this term is now used less often. Occasional ED isn’t uncommon. Most men experience ED at some time in their life and it can happen at any age. One fifth of men have more problematic ED. Because ED becomes more common with age, treatments were therefore initially specifically marketed for the older man. Viagra, the best known of these, was introduced for ED over 20 years ago, grossing $1 billion per year since for its parent company, Pfizer. Latterly, ED treatments have acquired a growing market among younger men, in particular when used in combination with recreational drugs. ED can occur because of problems at any stage of the erection process. An erection is the result of increased blood flow into the penis. Blood flow is usually stimulated by either sexual thoughts or direct contact with the penis. When a man is sexually excited, muscles in the penis relax. This allows for increased blood flow through the penile arteries, filling two chambers inside the penis. As the chambers fill with blood, the penis grows rigid. An erection ends when the muscles contract and the accumulated blood consequently flows out through the penile veins. Many men experience ED during times of stress. It can also be a sign of emotional or relationship difficulties that may need to be addressed by a professional. Frequent ED, however, can be a sign of health problems – so the specific underlying health problem needs treatment in addition to treatment of ED. Because erections primarily involve the blood vessels, it is not surprising that the most common causes of ED in older men are conditions that block blood flow to the penis, such as hardening of arteries or diabetes. Another vascular cause may be a faulty vein that lets blood drain too quickly from the penis. Other physical disorders, as well as hormonal imbalances, may result in erectile dysfunction. These include high blood pressure, high cholesterol, obesity, neurological disorders and low testosterone levels. Many drugs can cause ED, including those used to treat high blood pressure and sleep disorders. Excessive alcohol is a not uncommon cause of ED. So, all of these potentially contributing factors should be considered when evaluating ED. Treatment will depend on the underlying cause and may require a combination of approaches and medications. A number of variants of Viagra have emerged since its release; all are helpful. Sometimes, testosterone therapy may also be effective if levels are low but this is not common.