Reaching the menopause can often be met with feelings of anxiety and uncertainty about how you or your body may feel different. As we age, our body inevitably changes and some of these changes can affect self-esteem and sexual desire. Sexual problems affect 5% of women in middle age but many women feel unable to talk about it.
But menopause doesn't have to mean the end of sex. Many couples enjoy an active sex life into older age and some say it even gets better! Here we discuss our tips for having great sex after the menopause.
It's normal for your sex drive to vary throughout your lifespan. There is no 'recommended' frequency for sex. This is a choice that's personal for you. However, sexual desire may decrease when women reach the menopause.
The hormones oestrogen, progesterone and testosterone are all important in sexual desire. Falling hormone levels around the time of the menopause can result in middle-aged spread, hot flushes and drier skin - all of which can erode your libido. Sleep can also be disturbed and a lack of energy can also contribute to the problem.
But we can't blame hormones alone. At this stage in her life a woman may be juggling a job, a marriage and teenagers - often a recipe for increased stress levels that can put tension on a relationship.
Dr Heather Currie, spokesperson for the Royal College of Obstetricians and Gynaecologists and founder of Menopause Matters says: "It is common for women to lose interest in sex around the time of the menopause as hormone levels fall. This is often temporary and being able to talk things through with an understanding partner may be all that's needed. Other symptoms of the menopause can also indirectly contribute to a reduced libido, such as flushes, sweats, tiredness and mood changes. To treat these symptoms, HRT (which aims to top up oestrogen levels throughout the body) can be considered."
Communication is key
It's important to be open with your partner and discuss how you're feeling and what your needs are. Make time for each other by going on dates or having some quality time. Feeling loved, desired and secure is a core part of sexual relations. Remember, sexual intimacy does not always mean penetrative sex - it can be kissing, massage and oral sex too.
For some women, systemic (ie circulating in the blood around the body) hormone replacement therapy (HRT) can help with the troublesome symptoms of the menopause, reducing overall distress and, in turn, impacting positively on libido. HRT is either given in systemic form (usually as tablets or patches, absorbed into the bloodstream) or topically (as vaginal creams, pessaries, etc). Your GP can talk you through whether this might be an appropriate option for you.
Due to its active role in libido, some studies suggest that additional testosterone replacement may have a benefit on improving sex drive in menopausal women. Testosterone is produced by the adrenal glands and the ovaries, and levels start to fall from middle age. A type of tablet HRT called tibolone, suitable for women whose periods have stopped, may increase testosterone-like activity in the body. Other forms of testosterone replacement include an implant (inserted under the skin) or a patch.
In the UK, the National Institute for Health and Care Excellence guidance suggests testosterone's use for women with low sexual desire in whom HRT has failed. However, there are potential risks associated with androgen replacement and its use remains controversial. Currently there are no licensed products for testosterone replacement and it's not routinely recommended.
Dealing with dryness
A fall in oestrogen around the menopause can affect the tissues of the vagina, making them less moisturised and elastic. This can lead to vaginal dryness and discomfort which can make sex painful - a condition known as atrophic vaginitis.
A recent survey by 'Menopause Matters' demonstrated that 51% of menopausal and postmenopausal women experience vaginal problems, but sadly very few feel able to talk about them with their GP or partner. For many, these symptoms can have a profound effect on their sex life.
Try a lubricant
"A number of treatment options are available for vaginal dryness. However, women are encouraged to try self-help options first before seeking medical advice," says Currie.
"Regular use of vaginal moisturisers and lubricants applied to a woman's vulva, vagina or partner's penis to keep the vagina moist can help reduce dryness and discomfort. It is important to remember, however, that oil and petroleum-based products can damage latex condoms and irritate the vagina."
Water-based or silicone-based lubricants are recommended. Vaginal moisturisers such as Sylk® and Replens® can also be effective. To help treat the effects of a lack of oestrogen, topical oestrogen treatment can also be of benefit. Oestrogen creams, pessaries or a vaginal ring can be used to replenish the tissues and provide relief. The dose of oestrogen is so small it does not carry the same risks as the higher-strength systemic HRT.
Your pelvic floor
In addition to vaginal dryness and discomfort, some women may experience other urogenital symptoms with the menopause. Declining hormone levels can contribute to laxity of the pelvic floor. This can result in problems such as pelvic organ prolapse, stress urinary incontinence or urgency and recurrent urinary tract infections. All of these can present potential barriers for sexual relations.
What can help
The use of topical oestrogen creams or pessaries may help to alleviate urinary symptoms such as incontinence and urinary frequency and have also been shown to have a positive impact on recurrent urinary tract infections. Pelvic floor exercises can help to strengthen the muscles supporting the vagina, bladder and back passage - improving symptoms such as stress urinary incontinence, and pelvic organ prolapse. They can even make sex feel better too!
The silver lining
You'll be relieved to hear that it's not all bad news for your sex life after the menopause. Middle age has its benefits too.
Older children may have fled the nest and you no longer have to restrict sex to a tight window when the kids are in bed. You are free to have sex whenever and wherever you like!
Goodbye to bleeds
Around the start of the menopause, it can be normal to have heavier and more irregular periods. Once your reach the other side however, you are free from periods forever! Time to say goodbye to years of periods pains, tampons and sanitary towels. Many women in the menopause find that the absence of menstruation actually increases their sexual desire.
No pregnancy fears
Good news: if you are aged over 50, you can stop using contraception one year after your periods stop. If you are aged under 50, you will have to wait two years.