Common illnesses and medication may hinder sexual functioning after age 50. But you can learn how to regain physical intimacy.

By Natasha Persaud

Growing older doesn’t have to mean the end of a satisfying sex life. However, it does mean that you have to be proactive about caring for your health, which can make all the difference in your ability to be physically intimate. What’s also important is that sexual problems are more than a quality of life issue—they may be a warning sign or the consequence of a serious underlying illness. Here, experts share insights on maintaining your sexual health now and in the years ahead.

Sexual Health - MasterfileDoes sexual desire change with age?

Not necessarily, says Stacy Tessler Lindau, M.D., assistant professor of obstetrics/gynecology at the University of Chicago Medical Center. “Many older adults are sexually active, according to the National Social Life, Health and Aging Project [NSHAP], which my colleagues and I conducted in 2007. One in four adults ages 75 to 85, for example, reported an active sex life.

“The bigger issue is health. Health conditions that affect sexuality are frequent among older adults, but sexual problems are infrequently discussed with physicians, who can evaluate, diagnose and often treat the problems.”

What types of sexual problems do men and women experience?

“Men may experience erectile dysfunction, premature ejaculation, low libido or Peyronie’s disease, says John Mulhall, M.D., director of the Male Sexual & Reproductive Medicine Program at Memorial Sloan-Kettering Cancer Center in New York City. “These conditions cause obvious physical symptoms that should prompt a man to seek medical attention.”

Low testosterone is a common problem among older men. Symptoms vary from person to person, and may include fatigue, loss of body hair, bone loss, reduced sexual desire, hot flashes and sweats. If you or your doctor suspects low testosterone, a blood test will be ordered to test your levels. Even a man who experiences no symptoms should seek treatment, since low testosterone can lead to poor sugar control, osteoporosis and cardiovascular disease.”

For women, common sexual problems include lack of interest in sex, problems with sexual arousal, difficulty with lubrication, inability to climax, finding sex not pleasurable and experiencing pain during intercourse, says Dr. Lindau. Women frequently have concurrent problems.

“The NSHAP study also found a consistently strong relationship of stress, anxiety and depression, as well as poor mental health generally, with women’s reports of sexual problems—but men can also experience these problems,” says Linda Waite, Ph.D., Lucy Flower Professor in urban sociology at the University of Chicago, who coauthored the NSHAP study with Dr. Lindau. “If you’re feeling down, it’s harder to get excited about sex. That’s why it’s important to seek treatment from a mental health professional.”

What common health problems can affect sexual activity?

“Almost every medical condition that affects older people can have effects on sexual functioning,” Dr. Lindau says, “although the mechanism of those effects may differ.

“Someone with arthritis in the hips or knees, for example, could experience difficulty with certain positions in intercourse. In men, having either high blood pressure or diabetes can contribute to erectile dysfunction. Women with diabetes may have diminished orgasm, leading some to engage in sexual activity less often. Other conditions such as heart disease and cancer can also interfere with sexual functioning.

“On the positive side, many seniors who experience health problems still remain sexually active,” Dr. Lindau adds. “Although we need more evidence, it makes sense that treating the primary illness may give seniors a greater sense of well-being that could help them regain interest in sexual activity.

“Being sexually active can actually alleviate pain for some people, probably due to the release of endorphins following orgasm. For all of these reasons, it’s important for seniors to talk to their doctors about sexual health.”

Why do I need to see a doctor for sexual problems?

Sexual problems may be a warning sign or consequence of a serious underlying illness such as diabetes, an infection, urogenital tract conditions or cancer. Undiagnosed or untreated sexual problems, or both, can lead to or occur with depression or social withdrawal.

In addition, many people who are widowed or divorced are in the dating world for the first time in decades. “Even if you started having sex in an era when HIV was not an issue, it doesn’t mean that you’re immune to HIV or other sexually transmitted infections [STIs] now,” points out Dr. Mulhall.

Twenty-five percent of people living with HIV are age 50 or older; and genital herpes is a prevalent problem. “Even if you’ve had a hysterectomy [for women] or a prostatectomy [for men], don’t think that you can’t become infected with a sexually transmitted infection; you can,” says Dr. Lindau.

It’s important that men use latex condoms to prevent STIs. Arthritic hands or an incomplete erection may make it difficult to apply a condom; and poor lubrication may make condom use uncomfortable for some women. Your doctor can suggest ways to help these problems.

Talk to your doctor about prevention, having regular pelvic exams and whether you should be evaluated for STIs. Those that can affect seniors include HIV, herpes, genital warts, syphilis, trichomoniasis, gonorrhea and chlamydia.

“Your doctor may miss these problems, if you don’t bring them up,” Waite says. “Seeing your doctor allows you to get an evaluation, diagnosis, referral and treatment.”

Can medications affect sexual functioning?

Many medications that doctors prescribe to older adults are known to affect sexual function, says Dr. Lindau. “To the degree that medications make patients feel better, sexual function may actually improve. But, for many people, medications can have negative sexual side effects.”

  • Blood pressure medications may reduce men’s ability to have an erection.
  • Anti-depressants (SSRIs) may suppress libido in men and women, although some can have a positive effect.
  • Antihistamines taken on a daily basis can cause vaginal dryness.
  • “A patient may discontinue needed medications because of these effects. But you can work with your doctor to change your medication or the dosage to try to alleviate these problems,” says Dr. Lindau.

    Are there lifestyle changes that can improve sexual health?

    Although the scientific evidence is limited, there’s a fair amount of anecdotal evidence that being physically active, eating a healthy diet, getting good sleep and avoiding smoking and excessive alcohol consumption can help you stay sexually active.

    For example, doing aerobic activities to the extent that your health allows helps keep your body physically strong for intercourse, since they aid your heart, promote good circulation to the pelvic floor and genital tissues and maintain bones and joints. Exercises that increase flexibility, such as yoga, tai chi and swimming, can also help. Kegel exercises strengthen the pelvic muscles used in intercourse.

    Eating a heart-healthy diet that’s low in saturated fat, cholesterol and sodium, and high in fiber and nutrients from fruits, vegetables, legumes and whole grains will help keep your arteries healthy for sexual activity.

    If you drink alcohol, do so in moderation (the 2005 Dietary Guidelines for Americans suggest limiting daily alcohol consumption to two drinks for men and one drink for women) because too much alcohol can lead to high blood pressure and heart failure, which can hinder sexual functioning. If you smoke, quit:

    Smoking constricts blood vessels and impedes blood flow to genital tissues as well as other areas of your body.

    Don’t underestimate the value of quality sleep, either: Sleep maintains your energy levels and promotes good mental functioning, so aim for about eight hours of quality sleep a night.

    You'll also want to make time to relax during the day: “To relieve mental stress, try meditation, join a support group, participate in a community center or volunteer,” suggests the University of Chicago's Waite.

    Finally, focus on your romantic relationship. “Some older adults find it helpful to try different positions and new times for sexual intimacy, such as in the morning when you have more energy,” says Waite.

    “Sexual intercourse may be difficult, but cuddling, kissing and reaching out to your partner to show comfort or affection can help maintain intimacy,” adds Dr. Lindau. “Communicating with your partner is also critical. Often, couples affected by illness recognize that it’s affecting their sex life, but they don’t talk about it.”

    How can a doctor help with my sexual problems?

    “It’s your doctor’s responsibility to help you live as healthily as possible. Expect your doctor to listen, to take a sexual history, to conduct a physical exam and to work towards diagnosis and treatment,” says Dr. Lindau. Your doctor will also help you discover how health conditions and medications may be affecting your sexual functioning, and refer you to a specialist when needed.

    For men, Dr. Mulhall says, the physical exam is focused on testicular size, which can be an indicator of testicular cancer or low testosterone production, and examination of the penis. For women, the physical exam includes a pelvic exam that involves checking for thinning of the genital tissues, decreased skin elasticity, scarring or pain, and other specific examinations based on the complaint, says Dr. Lindau.

    “The physical exam is usually not as important as what you tell us,” says Dr. Mulhall. “That’s why it’s so important to talk openly with your doctor about your symptoms, medical history and sexual history, which involves only pertinent information, such as the number of current partners and condom use. Cultural, religious and comfort issues can be barriers to getting a good sexual history. I urge patients to be proactive and to ask questions to get the best care.”

    I’m embarrassed to bring up the topic of sexual health with my doctor. Any tips?

    First, know that you’re not alone. “Sexual problems are frequent among older adults, but these problems are infrequently discussed with physicians,” Dr. Lindau says. “About 40 percent of both men and women who were sexually active in the NSHAP study reported at least one bothersome sexual problem.

    “Many patients feel that they’d like to discuss sex with their doctor, but that the doctor should bring it up. With time and more information on how to help patients with sexual problems, we hope doctors will do better at raising these issues. If you have a problem and your doctor doesn’t ask, you should find a way to introduce your concern early in the encounter. Be direct and clear: For example, you could say ‘I’m having a problem with vaginal dryness and want to know if there’s anything I can do about it,’ or ‘I’m troubled by my lack of interest in sex. It’s dropped dramatically over the last few months and I don’t know why.’ I always counsel doctors to be direct with patients and to avoid beating around the bush; patients need to do the same. If you’re not clear about your problem, your doctor won’t know how to help you. This can be frustrating for you both.

    “There is a lot of silence and shame around these issues. Talking to a doctor can alleviate some of your worry. Speaking with a doctor is also an opportunity to learn more about your body.”

    Some physicians also feel embarrassed to discuss sexual concerns: “In a survey of American adults two-thirds of respondents hesitated to bring up the topic of sexual health with their doctors because they feared it would embarrass the doctors,” says Dr. Mulhall.

    “Not all doctors are adept at dealing with these issues,” explains Dr. Lindau, “but we’re working to train physicians, and offer them information to share with patients, so they can provide better care.”

    “I would like to see doctors ask about sexual health matters at the same time they’re reviewing the rest of a patient’s medical history,” says Dr. Mulhall.

    “If your doctor is hesitant to discuss sexual problems, ask who else you can see who has an interest and expertise in sexual health.”

    Any physician can treat sexual problems, including a family doctor, internist, endocrinologist, geriatrician, psychiatrist, gynecologist or urologist.

    Don’t be surprised if your doctor needs to do some research to get you the right referral. You can find helpful information on men’s sexual health and locate a physician at sexhealthmatters.org.

    Make a separate appointment to discuss sexual health. “Don’t do the ‘hand on the doorknob’ consultation, where you’re bringing up sexual health at the end of an appointment,” says Dr. Mulhall. You want your doctor to have enough time to discuss these matters with you.

    Should I bring up my partner’s health when talking with the doctor?

    Yes, says Dr. Lindau. When health problems interfere with sexual functioning, it affects both partners.

    “Erectile dysfunction, for example, is a man’s health concern, but it’s a couples issue,” agrees Dr. Mulhall. “This is true for most sexual problems.”

    By understanding your partner’s health, your doctor can better counsel you on treatments, and can offer suggestions as to how to talk about the problem as a couple. It also helps to educate you on what you can expect in your partner’s recovery.

    Are there times when I should consult a mental health professional?

    “Intimacy involves more than just physical health; your psychosocial health matters, too,” Waite points out. “Sexual problems among older people are sometimes the result of stress from relationship issues, an inability to do as much as they used to, financial worries and other concerns. It helps to talk about all aspects of your relationship, including the benefits of companionship and having assistance when you need it, in addition to sexual intimacy.

    A primary-care doctor may refer you and your partner to a psychologist (such as a sex therapist), psychiatrist or social worker to help solve the problem, and to make sure your mental health is as good as it can be. You may want to seek a mental health professional trained specifically in sexual dysfunction. The American Association of Sexuality Educators, Counselors, and Therapists (AASECT) offers a directory of certified sex therapists.

    What sex-enhancing medications are available?

    “Moisturizers and lubricants are available over-the-counter and by prescription to treat vaginal dryness,” says Dr. Lindau. “Hormonal therapies may be used to treat female sexual problems, such as estrogen therapy in the form of a vaginal ring, cream or pill to treat vaginal atrophy or dryness. For some women who have had their ovaries removed, androgen or testosterone replacement therapy may be helpful in addressing libido, but the FDA has not approved androgen therapy for this purpose. Many other drugs to treat a variety of female sexual problems are currently being tested in clinical trials.

    “For women, effective medical treatments for sexual dysfunction are limited. However, some problems are caused by or signal underlying medical or gynecologic problems, so sharing your symptoms can help your doctor find the right diagnosis and treatment. More information is needed about these treatments, so some of them may only be offered as part of a research trial. Hormonal and nonhormonal therapies can be beneficial for treating vaginal dryness, one of the most common problems experienced by older women.”

    Erectile dysfunction affects half of men over the age of 40 at some point in their lives. In older men, erectile dysfunction usually has a physical cause, such as disease, injury or side effects of drugs. Incidence increases with age: About 5 percent of 40-year-old men and 15 to 25 percent of 65-year-old men experience erectile dysfunction. But it is not an inevitable part of aging. “In the last decade, we’ve seen a growth in drugs to treat erectile dysfunction. Those medications have probably had a significant impact on older men’s sexual function, the duration of their sexual lives and the pleasure they derive from sex,” says Dr. Lindau.

    “For men with erectile dysfunction, we typically start with a pill, such as sildenafil (Viagra), vardenafil (Levitra) or tadalafil (Cialis)," says Dr. Mulhall.

    “The majority of men are helped by these medications. If a pill doesn’t help, the next level of treatment might include penile injections, a urethral suppository or a vacuum device. We might consider penile implant surgery for men for whom medical therapy wasn’t helpful, such as men with diabetes or those who have had radical prostate surgery.”

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    Published: 01 Sep 2008

    Last Modified: 26 Jun 2012