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American women live about 29 years after menopause and outlive their spouses for an average of 8 years. Although women tend to have less sex as they age, sexuality remains an important part of life for most older women. The sexual response of older women is influenced by many factors, including the following:

• changes produced by menopause
• social and cultural expectations
• relationship problems
• previous sexual experiences
• chronic illnesses
• depression
• medications
• behavior of sexual partner

Menopause is sometimes accompanied by less sexual interest and responsiveness. In addition, many menopausal women have problems with the urinary or genital tract that can make sex less enjoyable. These include urinary urgency, painful urination, urinary incontinence, vaginal itching, vaginal dryness, and painful intercourse.

Physical aspects of the sexual response cycle also change as women age. Older women often need more foreplay and direct clitoral stimulation for sexual enjoyment. Vaginal dryness can be a problem, although more foreplay and gentle stimulation can increase the amount of natural lubrication produced. Postmenopausal women also report reduced sexual sensation, which may cause them to feel and respond less during sex. Older women often have fewer and weaker orgasms, although they can still have multiple orgasms. Older women may also occasionally have spastic and painful contractions during orgasm. Most of these changes are thought to be caused by a lower level of estrogen after menopause, although age-related blood vessel changes may also cause problems with sexual function.

Many older women have pain during intercourse. The most common cause is vaginal thinning due to low estrogen levels, which results in decreased lubrication. Other possible causes include vaginal infections, bladder infections, vulvar cysts, pelvic tumors, too much penile thrusting, or improper angle of penile entry.

In some instances, pain may begin as a physical problem but take on a psychological aspect. For example, a woman may have an episode of pain during sex because of vaginal thinning after menopause. She may then anticipate pain with each later sexual encounter, resulting in less arousal, less lubrication, and continued pain. Because of this cycle, a woman may continue to feel pain even after the vaginal thinning has been successfully treated.

Older adults commonly have multiple medical illnesses, some of which affect sexuality. Women with diabetes generally report less desire and lubrication, and more time needed to reach orgasm. Diseases such as arthritis and heart disease can cause functional disability that limits sexual activity. Breast cancer can lead to sexual problems in many women, possibly because of poor body image (from mastectomy), marital and family problems, spousal reaction, or the psychological impact of a cancer diagnosis. Several drugs can also affect sexual function, including the following:

• antihistamines
• drugs for high blood pressure
• antidepressants
• antipsychotics
• antispasmodics
• antiestrogens
• nervous system stimulants
• narcotics
• alcohol

Social and cultural factors play an important role in sexual problems. American women commonly marry men older than themselves and live longer than men. As a result, many older women spend their later years without a partner. Lack of privacy may also be a problem when an older couple lives with their children or in a nursing home.

Social and cultural influences also include age-related assumptions about behaviors related to gender and sexual practices. For example, an older woman might think that sexual activity should be initiated only by a man. Another belief might be that there is only one correct position for intercourse or that intercourse is the only way of expressing intimacy. These assumptions may persist even in the face of physical or emotional changes that come with age.

Your healthcare provider can learn the most about your sexual concerns from an open and frank discussion with you. Unfortunately, older women are not typically comfortable volunteering information about sexual problems. It is important to find a physician that you like and trust, and with whom you feel comfortable discussing sexual concerns.

Your healthcare provider will need to ask you personal questions on matters such as pain during sex, vaginal lubrication, and previous bad experiences (eg, rape, child abuse, or domestic violence). Answer these questions as openly and honestly as possible. Your physician is there to help, and all information is kept in confidence.

A physical examination is an important part of any visit for sexual problems. This can include gynecological and neurological examinations directed at potential underlying problems. Laboratory tests may be required as well.

Treatment recommendations for various problems depend on the underlying cause.

Pain during sex caused by vaginal thinning and decreased lubrication responds well to topical or oral estrogen therapy. Improvements in genital tissue from estrogen supplementation also likely benefits arousal. However, 2 years of continual therapy may be needed to completely restore vaginal tissue and function. An "estrogen ring" can be a good alternative to oral pills or vaginal creams. The ring is inserted into the upper third of the vagina and replaced every 3 months. It continuously releases estrogen at a low dose, with little absorption into the body and fewer side effects.

Oral estrogen supplements have been linked to increased risk of stroke, cancer, and deep-vein thrombosis in postmenopausal women (see also Gynecological Disorders and Hormone Disorders). These risks are greatly reduced when using estrogen in preparations designed to be applied directly to the vagina (eg, creams, rings, or vaginal tablets). You should discuss the benefits and risks of estrogen supplementation with your healthcare provider.

Vaginal lubricants (eg, K-Y jelly) can provide necessary lubrication and decrease or eliminate pain during sex. Having sex regularly also helps maintain a healthy vaginal lining, maintains the size of the vagina, and increases lubrication. Longer foreplay allows more time for vaginal lubrication, just as older men often need longer and more direct stimulation to achieve an adequate erection.

Estrogen replacement can greatly improve the physical condition of genital tissue, but it has less impact on desire, or libido. Libido may respond to the male sex hormone testosterone, although testosterone is not approved by the FDA for decreased sexual desire in women. Sometimes, testosterone is prescribed in combination with estrogen for decreased libido in older women. Testosterone can have "masculinizing" side effects, such as growth of facial hair. These side effects are uncommon and, for the most part, reversible when testosterone treatment is stopped. Testosterone also has the potential to cause liver problems and should not be used in women with liver disease or high cholesterol. Typically, blood tests and liver function are checked before and every 6 months after testosterone treatment is started.

Psychological causes for decreased libido include depression, history of sexual abuse, and relationship problems. These should be addressed and treated with appropriate medications (eg, antidepressants) or counseling as necessary.

Sexuality is an important part of quality of life for all men. However, older men usually notice a distinct difference between their level of sexual interest in their later years versus what they experienced when younger. Often, men switch their focus from primarily physical to increasingly emotional relationships. Even so, many men who are older than 85 years old still have sexual interest.

Men's physical responses during sex also change with aging. Older men usually need a longer time to get an erection, requiring more intense physical stimulation than they needed when younger. Some men may perceive this need for added stimulation as an initial sign of impotence, which it is not. Orgasm often does not last as long and is less intense. The amount of time needed to have a second erection also increases.

Level of sexual activity, interest, and enjoyment in younger years affects sexual behavior as we age. In addition to the changes linked to aging, sexual activity can decrease because of a number of physical or psychological conditions:

• poor health
• social issues
• lack of a partner
• decreased libido
• erectile dysfunction
• disease involving blood vessels
• neurologic disease (eg, spinal cord injury)
• medications (eg, drugs for blood pressure or heart burn, antidepressants)
• hormone problems (eg, low testosterone levels, thyroid disease)
• psychological problems (eg, relationship issues, performance anxiety, childhood sexual abuse, "widower's syndrome")

Impotence, or erectile dysfunction is the most common sexual problem in men. It is defined as the inability to maintain an erection for successful sexual intercourse. This problem increases with age, and nearly 75% of men have experienced impotence at some time by the age of 70 years.

Erections are produced by stimulation of the nervous system. This stimulation can be physical or produced by sexual fantasy. Specific parts of the brain and nervous system control the various responses. Stimulation of the nervous system releases chemical substances that relax the blood vessels in the penis. Blood flows into these widened blood vessels, while blood flow out of the penis is limited. Flow of blood into the penis, along with decreased flow of blood out of the penis results in increasing pressure and stiffness or rigidity within the penis. During orgasm, chemical substances are released that allow blood to then flow out of the penis. Problems at any point in this process can lead to impotence.

Diseases of the blood vessels are the most common cause of impotence in older men. Risk factors include the following:

• diabetes
• high blood pressure
• high cholesterol
• smoking

Neurologic disorders are the second most common cause of impotence in older men. In men with spinal cord injury (eg, from disc problems), the severity of erectile dysfunction largely depends on the degree and location of damage. Those with severe damage to the spinal cord in the lower back and pelvis are more likely to develop impotence. Nervous system damage secondary to common health problems, such as diabetes, stroke, and Parkinson's disease, can also cause impotence. Surgery around the prostate, urinary bladder, or rectum may affect the nerve supply to the penis, resulting in impotence after the procedure (see Figure).

Many common medications can also cause impotence. The reason(s) for this are largely unknown. Likely drugs include antidepressants, antipsychotics, antihistamines, drugs for high blood pressure and some over-the-counter drugs (such as drugs for heartburn).

Testosterone in men maintains the genital tissues as well as sexual interest. Men with very low levels of testosterone have trouble developing erections in response to fantasy. However, testosterone plays only a small role in maintaining erections produced by direct stimulation. Overall, testosterone plays a minor role in erectile function and a major role in libido (desire). Other hormone disorders (eg, overactive or underactive thyroid gland) have also been associated with impotence, but this is rare.

Impotence can also be caused by psychological problems. Common psychological problems include relationship issues, performance anxiety, childhood sexual abuse, and fear of sexually transmitted diseases. Older men may have "widower's syndrome," in which a man feels guilt as a defense against subconscious unfaithfulness to his deceased spouse.

The first step in evaluating any sexual problem is a complete history. Your healthcare provider will need to ask many personal questions (see Table). Answer these questions as openly and honestly as possible. Your physician is there to help, and all information is kept in confidence.

• Defining the problem
  • Is the dysfunction really erectile failure?
  • Is the problem related to decreased sexual interest, ability to achieve orgasm, etc?
• Previous function
  • Compare quality of best erections when younger to that of current erections
• Onset
  • Sudden onset suggests psychological cause or adverse drug reaction
  • Gradual onset suggests an underlying disease
• Progression
  • Intermittent problems suggests psychological cause
  • Progressive problem suggests an underlying disease
• Duration of erectile dysfunction
• Are there erections on awakening?
  • Rigid erections during sleep suggest a psychological cause
  • Nonrigid or absent erections during sleep suggest an underlying disease or problem with medication
• Medical or social problems
  • Use of prescription or over-the-counter drugs
  • Economic or social stresses
  • Living situation (eg, lack of privacy)
  • Diabetes, neurologic disease, vascular disease, pelvic or abdominal surgery, mental problems
  • Alcohol and tobacco use
• Relationship with sexual partner(s)
  • Partner's health and attitude toward sex

A complete physical examination, including examination of the genitals, is an important part of any visit for sexual problems. Laboratory tests will likely include blood tests for diabetes, testosterone levels, and prolactin levels (another hormone involved in reproductive and sexual functions). Very high levels of prolactin can cause impotence even when testosterone levels are normal. Blood supply and blood pressure in the penis can also be checked by ultrasound.

A trial dose of Viagra may be tried. This drug causes an erection under normal circumstances, and a poor response suggests a blood vessel problem.

Several effective options are available for the treatment of impotence. Treatment should be individualized based on the underlying cause, personal preference, partner preference, cost, side effects, etc.

Three oral drugs are available for impotence: sildenafil, vardenafil, or tadalafil. These products have received widespread TV advertisements. These drugs generally work within 1 hour of administration, but have no effect without sexual stimulation. None of these drugs should be used if you are taking nitrate drugs (eg, nitroglycerin) for heart disease, because the combination can produce profound and fatal low blood pressure. Immediate medical treatment is needed if an erection lasts longer than 4 hours.

Vacuum pump devices are also used to treat impotence. These devices have a plastic cylinder with an open end into which the penis is inserted. A vacuum pump attached to the cylinder creates negative pressure within the cylinder, so that blood flows into the penis to produce rigidity. A constriction ring placed at the base of the penis then traps the blood within the penis to maintain an erection for about 30 minutes. Potential side effects include pain, swelling, bruising, and painful ejaculation.

Testosterone supplements increase libido and may improve erectile dysfunction in men with testicles that produce little natural hormone. Testosterone is available as an injection or as a patch or gel that can be applied to the skin. Possible side effects include thickening of the blood, increase in size of the prostate, breast development, and fluid retention (ie, "holding water"). The prostate is usually checked before and during therapy.

Sexual counseling and education strategies can be very effective in resolving sexual problems. Counseling can be a useful part of any therapeutic plan for older adults with sexual concerns. Counseling usually involves evaluating the expectations and knowledge of age-related changes in sexual activity.

Active communication between sexual partners is encouraged. Sexual problems may be a symptom of relationship problems in both younger and older adults. Older women should also receive education about sexual aging in men in addition to female sexual aging. Otherwise, she might mistakenly think her partner's diminished erection and need for more stimulation is caused by her own inability to excite her partner. Similarly, men should learn about age-related changes in women.

In the past, many healthcare providers have hesitated to offer sexual counseling, out of fear that such intimate discussion might offend their patients. However, recent experience suggests that people with problems are eager for advice and recommendations for solutions. Encourage your healthcare provider to share ideas and educational materials with you. For example, experimenting with various positions to reduce pain during intercourse can make a significant difference in sexual enjoyment for an older woman who has arthritis or other movement disorders. Similarly, other forms of intimacy, such as hugging, caressing, and manual or oral stimulation, can provide sexual satisfaction without traditional intercourse. Masturbation is an option for individuals who do not have a sexual partner. Even terminally ill people may have sexual needs or sexual problems, such as a need for reassurance from their sexual partner or a lack of closeness.