When it comes to sex and the problems middle-aged couples face with it, Laura Berman, the well-known therapist, author and frequent TV guest, had heard it all. And yes, that includes what she calls "that sandpaper feeling" menopausal women can have during the most intimate moments or — sometimes even harder to discuss — the breakdowns in desire that can happen during what she calls the "sex-romance stalemate." Here she talks about how women of a certain age can navigate their way to a much more connected and sex-filled future.
What’s a typical complaint or problem related to menopause that brings women, or couples, to your office in Chicago?
A common scenario I see is that a woman starts to have dryness, which makes sex hurt. So she starts to avoid sex because it hurts and she also doesn’t have the same level of desire. Also, she’s tired as hell because she’s not sleeping well, or she might be moody and frustrated, and the last thing she feels like is having sex. The cost-benefit analysis is just not in favor of it.
But not having sex doesn’t go over so well if she’s married.
Men really achieve that sense of emotional closeness and connection — which women can get through talking and cuddling and spending time together — through sex. That’s the primary way they feel emotionally close to us. And so if she withdraws from sex because it hurts or it’s uncomfortable or she’s too tired, he doesn’t have a way to tune in and be romantic or cuddly or whatever else makes her feel loved. So as she withdraws from sex, he withdraws emotionally, which makes her that much less interested in sex! And this is what I call the "sex-romance stalemate," and I would say that in menopausal women that is one of the main issues that I see.
And, of course, this is different than what we used to see a generation or so ago. If you think of the generation that was the boomers’ parents, they pretty much stopped having sex around the time the woman was menopausal, because he couldn’t get an erection.
And there was no Viagra to help him.
Right, and I remember when it came on the market in 1998. All these older women who were perfectly fine with having no sex — and whose husbands were perfectly fine with having no sex because they couldn’t get aroused — suddenly, all these women were expected to have sex. The guys were taking Viagra, getting an erection, and jumping on their wives with no foreplay. So it was great that men could have sex, given how important sex is for your health, and how it helps men's immune systems, blood flow, prostate … but at the same time, it was a real struggle for women because they didn’t naturally find it easy to gin up the desire.
Especially on demand?
Right! I remember one woman telling me, “He takes the Viagra and then he goes out and mows the lawn, and then he comes back in the second he has an erection, and he’s ready to go.” That’s a whole different conversation. These were guys who hadn’t had an erection for so long that they were scared it might go away.
So all these women flooded into your office …
Flooded! And that’s what started the Viagra studies in women. These women were coming in and saying, "Can you give me some of that, too?" But, of course, it didn’t prove to be that effective for women — with the one exception being women who have low arousal due to taking antidepressants.
When you look at menopause, what’s going on hormonally that affects a woman’s sex life?
Basically, lubrication is a direct result of estrogen. The more estrogen you have, the more lubrication you have. So as your estrogen starts to decline you will have difficulty with dryness as well as thinning of the vaginal walls. They become more brittle, hard, thin, easily torn — that’s all primarily from falling estrogen. Testosterone is known as the hormone of desire, and that plays a role not only in sexual desire but also in sexual response, in things like nipple and genital sensation. And then there’s progesterone decline, and that plays a role in weight gain and sleeplessness and moodiness.
We hear a lot about estrogen replacement therapy, but what can you do for the testosterone part?
There are a ton of testosterone interventions out there for men, but no FDA-approved testosterone treatment for women yet. Certainly, many doctors out there are recommending things like DHEA supplements that may support testosterone growth or development naturally. And a lot of doctors are prescribing testosterone off-label. There was a testosterone treatment for women on the table for a while, but a group of people came out against it because they felt like low desire should not be a medical condition. And of course I disagree with that!
Do you think it’s a matter of women having to demand that their sexual issues get the same attention men’s do?
I think so. I think boomers really have to drive this. It's like, they spearheaded the women’s movement, they can spearhead creating more medical options for the medical causes of women’s sexual function complaints! The demand has to be there for a pharmaceutical company to invest and do the clinical trials and pay for all that it costs to get it FDA approved.
When you were listing the health benefits of sex that men who take Viagra enjoy … are there similar health benefits that come from extending women’s sex lives?
Yes, I mean, really … First of all, it’s good for our hearts, good for our nervous system, good for our relationships in the ways I mentioned. Sex is good for your immune system, and it also actually helps with menopausal symptoms — in some cases because you’re flooding your body in those feel-good hormones. You’re also putting coins in the emotional intimacy bank, and the greater your emotional intimacy the longer you’re going to live.
What is the first line of treatment if someone is experiencing pain with sex?
Hormones, although a lot of women can’t take hormones and other women don’t want to. For most perimenopausal women, I would encourage the use of lubricants, whether they feel they need one or not!
Because it just makes sex better?
Yes; we think lubricants are only for old ladies, and that’s not the case. I’m a big fan of them. If you want something more organic, try organic coconut oil, the same stuff you cook with, or all the K-Y options at your local drugstore. They even have a product called Liquibeads that you can get over the counter, which lasts for three days after you pop one into your vagina. Baby boomers who are dating someone new or who don’t want to start sex with lubricants tell me they like this option.
And beyond the over-the-counter stuff, what do you recommend?
Osphena, an oral medicine for postmenopausal women experiencing pain, is one really easy way to tackle lubrication. It acts like estrogen to help with blood flow and lubrication, but it’s designed to avoid [absorption into the] breast tissue. Obviously, you have to talk to your doctor to weigh the pros and cons, but it can be better than traditional hormonal therapy if you are concerned about breast cancer or have a history of breast cancer.
On to Kegels. Do you do them ... forever?
Kegel exercises are so important. Doing them not only can give you a stronger orgasm but can help with things like bladder leakage or prolapse of the uterus or vagina. And so can core work, which helps build up the whole hammock of muscles that hold up your pelvic floor. You should specifically work on your transverse abdominals, the wall of muscles that surrounds your torso. These play a role in sexual response, too.
Ever had clients who find that — maybe with some work — sex can be more enjoyable in the postmenopausal time of life?
It can be amazing! Better than it ever was. But the menopausal woman has to accept that desire needs to come from an emotional place, it’s not necessarily that drive of, Oh my gosh, I have to get laid! It’s more from a place of wanting to be close to her partner, wanting to love them in a way they can feel intimate.
I’ve counseled so many boomer couples who are just loving life in this way. With their kids grown, they may have fewer distractions and more space and time for sex — and for foreplay in particular. They can nurture and attend to their sex life. They’re vacationing in different spots and doing it in the woods ... they’re taking their time with afternoon cuddling ... or walking around the house naked. And being less self-conscious can be a boon to the sex life, too. If we’re developing emotionally properly, we get more and more comfortable in our own skin as we age.
So women need to embrace a little different motivation for sex. But do you ever have to educate men in terms of giving foreplay more time?
To my couples over 40, I always say, embrace the vibrator, guys. It’s not gonna replace you. As we reach into our 40s, women need more stimulation, and we need more foreplay to get there. It takes longer to reach orgasm, and orgasms aren’t necessarily as intense.
If someone wants to talk about their sexual issues related to menopause with a professional, do you start with your doctor? How open are most, really, to this?
Most doctors are not going to bring it up unless you do. You have to be your own health advocate in all areas, and especially in this one. But if you bring it up at your checkup, they can help find out what’s going on hormonally, and they can talk about your medical options, taking into account any of your personal risk factors.
Otherwise, if that sex-romance stalemate has really taken on a life of its own, or if you’re having issues involving sexual communications, or struggles with pleasuring each other, or if inhibitions are getting in the way, you really want to see a sex and relationship therapist. A great resource for those can be found at the website of the American Association of Sexuality Educators Counselors and Therapists, which is aasect.org.
I love how encouraging you are about older women’s sex lives. Because reading articles about “the thinning of vaginal walls” for the 10th time can make it all start to sound depressing.
A Chinese medical doctor once told me the chi — the life force, according to Chinese medicine — in a woman’s body is always flowing down to her reproductive organs until perimenopause, when it literally changes directions. That energetic shift, the thinking goes, is why we’re misfiring during that time. But then, he said, you move through menopause, and the chi, the life force, is now flowing to all parts of your body and not all just centered on your womb. And it’s at this age and stage that women in most societies gain the most status, because they’re the wisest, most grounded, most intuitive. They’re in a very empowered place emotionally. It’s an amazing time in life if you let go of the societal stereotypes about it.