We all remember Maslow… don’t we? That noted psychologist who, in 1954, published his famous hierarchy of human needs that we all learned about in high school psychology?
Maslow determined that we all have basic physical and psychological needs that fall into an orderly hierarchy and are necessary to achieve happiness. But, he propositioned, basic survival needs for food and shelter had to be met before we’d benefit from higher levels of need fulfillment, such as the love and belonging or self-esteem.
To test whether Maslow’s theory would hold up under modern scrutiny, two researchers designed a massive Gallup poll of well-being. Almost 61,000 people in 123 countries were quizzed about fulfillment of specific needs and daily feelings of joy and unhappiness as well as on overall life satisfaction. Maslow was correct that people everywhere share the same basic needs, beginning with physical needs and ending with self-actualization (a “fuzzy” term that scientists don’t much like).
However, this survey found that, although Maslow was on target about his list of universal human needs, he was wrong about their orderly nature. People seem to need everything all at once. People can (and do) enjoy the higher-level needs for love and friendship, for example, even if they may be lacking some basic needs. “They’re like vitamins,” said one of the researchers in a recent article in the Atlantic. “We need them all.”
So where do we fit in—midlife women who probably have our basic physical needs met, but who still are actively engaged in life’s endeavors?
While the Gallup researchers were revisiting Maslow, Jaki Scarcello, author of Fifty and Fabulous, was conducting a little survey of her own, interviewing older women between the ages of 45 and 102 around the globe. She wanted to find out what happens when women grow old. How do we evolve?
What she discovered was that many of us do indeed reach Maslow’s highest levels of human development. We become wise, accepting, purposeful—you know, self-actualized—and this at times despite living under difficult challenging circumstances at times.
“I think the Maslow link is that perhaps self-actualization and improved self-esteem are more available to us as we age, which, ironically, may be a time in our lives when our basic needs are once again threatened,” said Jaki.
Jaki calls these the Women of the Harvest.
“Many older women told me they were experiencing a confidence they had never felt before in their lives,” says Jaki, “that they had found their voice, they were daring to do things they had not dared to do before.”
Younger women, on the other hand, tend to look to external sources for validation, to be more invested in appearances, and to be more distressed when basic needs weren’t met.
This serenity and self-acceptance applies to our sexual selves as well. “And so our sexuality is still important to us, but it does not suffer as much interference from self-deprecating mind chatter and from external reactions,” she said.
So, despite the physical and emotional changes of aging, we may be more confident in our own sexuality and look to others less for approval and validation.
“If it seems that the sparkle in a Woman of the Harvest deepens with age, perhaps it’s because her fire is fed in part by the internalization of sexual energy. This beauty is truly no longer skin deep. Instead, it radiates from some knowing place inside a woman who has ceased to need the outer world to know herself,” writes Jaki in Fifty and Fabulous.
I’ve talked about a couple of general topics prompted by reading the REVEAL research results: that lots of women aren’t aware of the effects of menopause on sexuality and that many of us aren’t talking about it. There’s one more topic that’s on my mind, because I hear about it every day in e-mails I receive from the “Ask Dr. Barb” link on our website.
It’s painful intercourse. In the study, 36 percent said that pain during sex made them stop having sex. That’s one issue. The other issue is that 59 percent of women who experience pain during sex still have intercourse on a regular basis. About three-quarters of those women have sex at least once a month, on average; a third have sex at least once a week.
The good news for the women among the 59 percent is that they recognize their sexuality as an important part of their selves and their relationships. The bad news, of course, is that it hurts. And more bad news is that not enough women realize that it doesn’t have to.
When midlife women talk about their sexuality, pain with sex is easily the most common physical complaint. This pain may feel superficial or deep. It may feel like burning or aching. It may happen only on initial penetration or only with deep thrusting.
The medical name for this is “dyspareunia" (dis-pu-ROO-nee-uh). It’s a tongue twister of a word, I know, but it comes from “dys” (as in dysfunctional) plus a Greek word that means “lying with”—so it’s as simple as “lying together doesn’t work.” It’s a general diagnosis that needs more investigation, because many things can cause the pain, and the pain can be experienced in a number of ways.
Another scary part of the research: A quarter of the women who experience painful intercourse thought that there was “nothing that could be done medically” to address their pain; I assure you that’s not true. There are solutions ranging from regular use of moisturizers and personal lubricants to overcome dryness to vaginal dilators to restore vaginal caliber (size and depth of the opening) to systemic or vaginal estrogen to maintain tissue health.
About a quarter also felt that their pain during sex was “an inappropriate conversation” to have with their health care provider; that’s not true, either.
Easy for me to say, I know, since I specialize in mid-life women’s health. Whoever your health care provider is, he or she will recognize the importance of sexuality to a full and healthy life. And if you don’t sense that, it’s worth it to find a sexually literate health care provider. Really.
I had a call the other day from a friend who’s been a widow for several years. “I’ve found someone!” she told me, with just the slightest quiver in her voice. “I’m so excited I can hardly concentrate at work.”
Of course I was happy for her -- and happy that she called to set up an appointment with me for an exam in anticipation of resuming her sexual life. “I think everything’s going to be okay,” she said, “but I think I might want to come in and see you first so you can tell me for sure.”
She did come in to see me and I was glad to be able to reassure her that, from a physical perspective, she was good to go. If I am able to place two fingertips in a patient’s vagina without causing pain or discomfort, it’s a good bet that she’s going to be able to have intercourse comfortably.
But more than a few post-menopausal patients who come to my office have been astonished to discover that they can’t pass the two-finger test. Their vaginal walls have narrowed and thinned over a period of time without regular intercourse, and I have to tell them it’s going to take some work to get back into a condition where penetration will even be possible, let alone comfortable.
I run into this fairly frequently with women who are widowed and divorced at our stage of life. They are grieving or angry -- or both -- and, without thinking too much about it, decide that their sexual days are behind them. Don’t need to worry about that anymore! But, as my ecstatic friend can attest: You never know. Surprises happen, and when they do, it sure would nice to know that your body’s ready and able to experience the pleasures of intercourse.
It’s one of my biggest concerns for single women our age. If you’re 30 when you divorce and 40 when you want to take it up again, there’s been no lost ground. But if you’re 50 and decide to resume sex at 60, it’s a very different story. You find yourself in a new relationship, you’re ready to be intimate, but your vaginal “architecture” has changed. It can be a very unhappy surprise.
Physical therapy with vaginal dilators can help to restore capacity for intercourse, but it’s much simpler -- and more pleasant! -- if you don’t lose that capacity in the first place. For all my patients and friends who are currently without partners, I recommend a “vaginal maintenance plan” that will help them keep their genitals healthy and ready for love: moisturize regularly; use a good lubricant; and experiment with a personal vibrator or dilator to preserve your capacity for penetration.
Because you never know.
This is an important issue. At 49 you are ‘subfertile,’ but not infertile. You also can’t rely on rhythm, as there is no rhythm!
Barrier methods--condoms or a diaphragm--can work well, although they take some anticipation and planning. (If you're in a new relationship, you might also consider the protection condoms provide against STIs, too.) If you choose that route, intravaginal spermicides in combination with the barrier will give you some additional coverage. The birth control pill, which is approved for use until age 55 or menopause, can still be an option. If you did well on it in the past, you would likely do well on it again; a careful health history would help make sure you are a good candidate. Now pills can be given in such a way that you menstruate much less often, or not at all. And one more option: There is an IUD on the market that lasts 5 years--likely to get you to menopause.
What you choose depends on your health history and your personal preferences. I'm glad you're both enjoying your sexuality again and paying attention to this issue!
She's 54 years old. She's spent most of her adult life in a long-term monogamous relationship. She's just been diagnosed with genital herpes.
This happens more often than you might think.
Even I -- who should know better! -- have been guilty of age bias when it comes to testing for sexually transmitted infections (STIs, also called STDs, for sexually transmitted diseases).
In my former practice, when a 20-year-old came in presenting with symptoms (discharge, discomfort, irritation) that might indicate an STI, I would automatically screen her. When a 50- or 60-year-old came to me with the same symptoms, I was more likely to ask before I tested: "Is this a possibility?" If she said "no," I tended to trust that. I was trusting my patients. They were trusting their partners.
Times have changed.
Over the past decade, STI rates among people 45 and older more than doubled. In April, the Centers for Disease Control and Prevention reported that senior citizens accounted for 24 percent of total AIDS cases, up from 17 percent in 2001.
Researchers point to climbing divorce rates at mid-life, the rise of online dating services, the increasing number of men availing themselves of treatment for erectile disfunction. And all of these are contributing factors, I'm sure. But in my experience, the most likely cause of the up-tick in STIs among women past their child-bearing years is lack of awareness and prevention.
If you know that pregnancy is not a possibility, why use a condom?
Unfortunately, the risk of contracting STIs -- including syphilis, gonorrhea, genital herpes, HPV, hepatitis B, and HIV -- does not end at menopause. In fact, sexually active postmenopausal women may be more vulnerable than younger women; the thinning, more delicate genital tissue that comes with age is also more prone to small cuts or tears that provide pathways for infection.
And -- it's not fair, but there it is -- with almost every STI, exposed men are less likely to experience symptoms, simply because they don't have the equivalent of a cervix and a vagina and the skin of a vulva. The kind, older gentleman who gave my 54-year-old patient genital herpes might honestly not have known he was infected.
These days, when a 50-or-60-ish woman shows up in my office with symptoms that point to a possible STI, I go ahead and screen. I'll say, "I understand this is not a likely outcome, but I want to make sure I'm checking all possibilities."
Worry about STI can be a real drag on sexual enjoyment. We'll talk about what you can do to insure that contracting an STI is not a possibility for you in my next post: "When Was the Last Time You Used a Condom?"
Oh, where do I begin? Perimenopause can be a pretty tough transition for many women. It is not only possible but probable that those symptoms are related. Patients with these complaints get a one-hour appointment in my practice to review the signs and symptoms that accompany this transition.
Riding it out is one option. Above all, make sure you optimize lifestyle, with exercise being probably the most important factor. Aerobic exercise of 45 minutes 5 days a week along with 60 minutes each week of strength training is a great goal to set.
I often recommend a book to patients: Dr. Robert Greene's Perfect Balance. It covers this transition quite well and reviews options in treatment including diet, exercise, and hormone alternatives. It was originally published in 2005, but is still one of the best I have seen.
Good luck! Things will get better!
A big bouquet of roses waited for me at the front desk of my clinic.
It wasn’t my anniversary or my birthday. And doctors just don’t get a lot of flowers. When I saw who sent them, I smiled that special “good sex” smile, even though the sex I was smiling about wasn’t my own.
I've been a women's health doctor for more than 20 years, focused on midlife women for the past four. These flowers were not from a new mom or a patient with a difficult disease. These came from a patient who got her sex life back.
That may not seem like a big win in the scheme of things, but it was a wake-up call for me. My patient, now in menopause, was distraught that her sex life seemed to be over so soon—too soon. Sex was effortless for most of her life. It had been very satisfying. And suddenly, it wasn't any more.
We talked about sexual response with her hormonal changes, all of the many factors that could be influencing her experience. Then we talked about her options for managing these changes. She tried different routes, but when I introduced her to a device—she had not used them before—that made the difference for her. With the help of a simple tool, she was able to adapt to her new reality, and enjoy sex again.
It was a fairly straightforward doctor-patient exchange, but not a common one. Women rarely talk to their doctors about sex. As a menopause practitioner, though, I know that changes in sexual response are a key source of distress for a lot of women and their partners at this age.
Is it a doctor's job to help their patients have good sex? I think it is, absolutely. A healthy sex life sustains our overall health and well-being. Sex is good for us, and helps us to remain vibrant and strong. Menopause isn't a disease. It's a natural process. The more we understand this process, and discuss it openly, the easier it will be for us to make adjustments to accommodate our bodies' changes.
The roses were evidence that my patient's sex life had been restored. How many women like her have never raised the question with their doctors. Their gynecologists? Or sisters? Or friends?
Natural changes during meopause can make it feel like the door is closing on your sex life. For some of us, that’s not a huge loss. For others, it’s seriously distressing.
But these changes don't have to stop your sex life. They will certainly change things a bit. They may require learning some new things, trying some new techniques, experimenting with a few products.
I'm working with my friends to launch MiddlesexMD. We will reach out to women like my patient, women at midlife who aren’t ready to close the door on sex, and who aren’t sure how or when to talk with their doctors about their experiences. My partners and I want to build a trustworthy (and bouquet-worthy!) sexual health resource for midlife women, combining helpful advice, clinical expertise and a carefully selected set of products with a record of helping women continue to enjoy a satisfying sexual life as they age.
By launching our blog first, we're starting the conversation. We'd love to hear what you think, need, want. What do you think about a website devoted to midlife sex? Can you relate to the changes in your sex life? Please leave a comment to join the discussion, and/or sign up to receive the posts by email.