When it comes to sex after 40, one of the biggest misconceptions is that age will sour your sex life. But in reality, many women in midlife say the quality of sex is better than ever.
Listen in as Cheryl Iglesia, MD, discusses myth vs. reality about midlife sex.
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Midlife Sex: Myths v Reality
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Learn more about Cheryl Iglesia, MD
Cheryl Iglesia, MD
Cheryl Iglesia, MD, is a leader in the field of female pelvic medicine and reconstructive surgery and is nationally recognized for advancing surgical techniques, clinical research and medical education. She is an expert clinician renowned for her skills in diagnosing and treating pelvic floor disorders. Among many roles, Dr. Iglesia is the current chair of the Advisory Board for the Pelvic Floor Disorders network at the Eunice Kennedy Shriver National Institute for Child Health and Human Development (NICHD) and is the immediate past chair of the Committee for Gynecologic Practice at the American Congress of Obstetricians and Gynecologists(ACOG). She has served on the board of directors of the American Urogynecologic Society (AUGS) and the AUGS Foundation and was appointed as the inaugural chair of the AUGS Guidelines committee. She currently serves as vice chair on the Patient Education Board at ACOG and is an appointed special governmental employee for the ObGyn Devices Panel at the United States Food and Drug Administration (FDA).Learn more about Cheryl Iglesia, MD
Transcription:
Midlife Sex: Myths v Reality
Melanie Cole (Host): When it comes to sex after 40, one of the biggest misconceptions is that age will sour your sex life. Is that a given? Does it have to be that way? My guest today is Dr. Cheryl Iglesia. She is a Urogynecologist with MedStar Washington Hospital Center. Welcome to the show, Dr. Iglesia. What do you see, that women and men ask you, are the biggest myths when it comes to midlife sex?
Dr. Cheryl Iglesia (Guest): I’m so happy to be here, Melanie, and I just love talking about sex. When it comes to midlife, I think that some of the biggest myths are relating to performance anxiety and that things don’t work as well when you get older. Organs can be out of place, blood flow may be less and so people feel less confident and then they just do it less and then it becomes a ho-hum thing. And I think that the biggest miss is that there’s a lot of things that you can do to reverse it and there’s a lot of things you can do to prevent it to maintain your sex drive and your sex life.
Melanie: Let’s start with women, what do you see as some of the biggest challenges because, as women are going through perimenopause and into menopause certain things get drier, our hormones have changed. all kinds of things change with our bodies.
Dr. Iglesia: Yes, I think if you specifically map it out, by three years past menopause 50% of women have dry vaginas. There’s a new term that’s been coined called GSM, it’s like the EG for women, but GSM is “genitourinary syndrome of menopause.” So, we can say on air instead of using “vulva and vagina atrophy,” which sounds terrible. What it refers to is a lack of estrogen and the changes in the hormonal milieu of the vagina that lead to drier tissues that affect not only the vagina and the vulva structures but also the urethra, the bladder and some of the surrounding glands.
Melanie: Do you ever recommend for some of these challenges topicals, some of those testosterone creams, progesterone creams that we see on the market?
Dr. Iglesia: Yes, there’s nothing worse than sandpaper sex. So, if it’s dry, wet it. It’s almost you can’t get it too wet, right? So, the thing about it is generally speaking, obviously, you should be evaluated, making sure that you don’t have any skin conditions or any other infections, yeast infection or otherwise. But you start topically and what most people recommend is you can start with either a lubricant during sex or a moisturizer, both of which are non-hormonal. And there’s differences between lubricants, most of which have silicone or they’re water-based, and there’s lots of the out there. We kind of steer away from some of the ones with mint or menthol or heat because that can burn, particularly a drier vagina. And that’s during sex, but apart from sex you can use a moisturizer, many of which are designed to replace the pH. It’s a little bit more of an acid, mild acid to keep the pH—so, it’s more acid, 4.5, and that keeps the healthy bacteria from staying around and not getting an overgrowth of unhealthy bacteria.
That doesn’t work for everybody, though, and after that we would move to hormonal topical treatment. And the only FDA-approved ones have estrogen, and these are very different from the estrogens that you take by mouth. There is one that’s designed to take by mouth. But the topical estrogens are creams, Estrace, Premarin, and there’s a tablet called Vagifem, and then there’s a ring Estring that stays in for three months and, generally, the partner can’t feel it. That just releases daily estrogen for three months. Now that is all FDA-approved and the doses are so low that there really is not any significant cancer, blood clot or heart disease risk for that. There are no FDA-approved treatment options for testosterone. I know that many people find that helpful and they have to get through compounding pharmacies. We just have to find someone who is monitoring that because if you do absorb too much testosterone, not only can the clitoris grow but then you can get more hair in unwanted places and balding and acne and maybe some heart issues from that, or lipid issues.
Melanie: I think another issue is libido and desire. We seem to go up and down in our lives with that, and men, of course, they have Viagra and they have all these things and, boy, they tout that stuff, but the women they came up with that female Viagra, which is not really that. So, speak about women and desire and libido and how we can ramp that up a little bit.
Dr. Iglesia: There’s a lot of things that go into desire, and the new Flibanserin, which has been touted as the female Viagra, you’re right, Melanie, that isn’t for everybody and doesn’t help, and you can’t drink alcohol, for one, with it. But, it is only FDA approved for women who are premenopausal. It’s not actually not FDA approved for people who are postmenopausal, and we don’t have any FDA approved drugs. And some people feel that testosterone levels, men have Low T, women can suffer from Low T, but there’s a lot of things that go into desire, just in terms of the way women feel about their bodies. I think there’s a lot of concern about body image. I think that some changes that can occur in the architecture of the vagina, particular after you’ve had children. It takes longer to have orgasm, maybe you don’t feel as much, and they’re just feeling very different about their bodies, less confident. And then, there are relationship issues. In addition to that, there’s menopause. I mean, we have the women and we have 30% of them by the time they’re over 50 have dry vaginas. Well, 50% men over 50 have erectile dysfunction, and 60% over 60, and 70% over 70, so there could be some relationship issues and some performance issues on the partner side, and this is assuming heterosexual relationship, obviously.
Melanie: So, what do you tell couples and/or women every single day, Dr. Iglesia, about ways to combat some of these libido issues, body image issues, all of these things? With men it could even be prostate issues.
Dr. Iglesia: Yes, you have to change it up. I mean, I’m not going to say personally, but I have been married to the same guy for now 23 years, and you can’t be doing the same thing. You’ve got to change up. Everybody’s got to change their game. I would say change the location, change the time of day, get some toys in there. There are so many good ones that are out there now. These Lelo vibrators, and then they have these new cock rings, and there’s just a lot of new things that you can experiment with. It may take a little bit longer because blood flow is going there, but now you can use that little Gigi vibrator right on the clitoris. And now, we have special enhancers and arousers just specifically designed to bring more blood flow to that vital area. So, change it up. Read the Kama Sutra, look at different positions, start doing other fun things together to revitalize your relationship. I have to say, at this point in our life, and I have children and they’re grown, you really have to have invested in that relationship with your partner. And, if there are issues, I find that referring out to a sex therapist or couples therapy, making sure that everything is working, just in terms of blood flow and blood pressure and checking on meds that could have a negative impact. Anti-depressants can have a pretty significant impact negatively towards women’s drive and even arousal and some of the blood pressure medicines, in particular, as well. So you need a pretty comprehensive evaluation that can’t be done during your regular routine annual check-up when you’re getting your mammogram, and your breast, and your pap smear, if it happens to be that time. You have to have a separate exam and you’re got to make this priority. It’s nice, I think, when couples come in, whether they be male-female, female-female, whatever, just to talk about some of the issues.
Melanie: What absolutely great advice. Just wrap it up for us, Dr. Iglesia, with your best advice, as couples come to you or women come to you with questions about these myths and misconceptions about sex as it gets into the ages.
Dr. Iglesia: I would say don’t give up. If it’s something that’s really bothering you and really bothering your partner and you really want to make improvements, don’t listen to a gynecologist that says, “Well, what do you expect, Melanie, you’re getting older, and this is what happens.” You don’t have to suck it up. You can divorce your gynecologist. You can see a specialist and someone who’s going to validate these concerns and maybe offer a very thorough evaluation, give you the appropriate referrals, give you the permission to and some advice on other things to try because it’s really a whole new world order and we don’t have to settle for sandpaper sex. We don’t have to settle for lack of arousal. I think you can resume that zest and your drive, and you can maintain it, and it’s totally possible.
Melanie: Thank you so much. What an amazing guest you are, Dr. Iglesia. Thank you so much for being with us today. You’re listening to Medical Intel with MedStar Washington Hospital Center. For more information you can go to medstarwashington.org. That’s medstarwashington.org .This is Melanie Cole. Thanks for listening.
Midlife Sex: Myths v Reality
Melanie Cole (Host): When it comes to sex after 40, one of the biggest misconceptions is that age will sour your sex life. Is that a given? Does it have to be that way? My guest today is Dr. Cheryl Iglesia. She is a Urogynecologist with MedStar Washington Hospital Center. Welcome to the show, Dr. Iglesia. What do you see, that women and men ask you, are the biggest myths when it comes to midlife sex?
Dr. Cheryl Iglesia (Guest): I’m so happy to be here, Melanie, and I just love talking about sex. When it comes to midlife, I think that some of the biggest myths are relating to performance anxiety and that things don’t work as well when you get older. Organs can be out of place, blood flow may be less and so people feel less confident and then they just do it less and then it becomes a ho-hum thing. And I think that the biggest miss is that there’s a lot of things that you can do to reverse it and there’s a lot of things you can do to prevent it to maintain your sex drive and your sex life.
Melanie: Let’s start with women, what do you see as some of the biggest challenges because, as women are going through perimenopause and into menopause certain things get drier, our hormones have changed. all kinds of things change with our bodies.
Dr. Iglesia: Yes, I think if you specifically map it out, by three years past menopause 50% of women have dry vaginas. There’s a new term that’s been coined called GSM, it’s like the EG for women, but GSM is “genitourinary syndrome of menopause.” So, we can say on air instead of using “vulva and vagina atrophy,” which sounds terrible. What it refers to is a lack of estrogen and the changes in the hormonal milieu of the vagina that lead to drier tissues that affect not only the vagina and the vulva structures but also the urethra, the bladder and some of the surrounding glands.
Melanie: Do you ever recommend for some of these challenges topicals, some of those testosterone creams, progesterone creams that we see on the market?
Dr. Iglesia: Yes, there’s nothing worse than sandpaper sex. So, if it’s dry, wet it. It’s almost you can’t get it too wet, right? So, the thing about it is generally speaking, obviously, you should be evaluated, making sure that you don’t have any skin conditions or any other infections, yeast infection or otherwise. But you start topically and what most people recommend is you can start with either a lubricant during sex or a moisturizer, both of which are non-hormonal. And there’s differences between lubricants, most of which have silicone or they’re water-based, and there’s lots of the out there. We kind of steer away from some of the ones with mint or menthol or heat because that can burn, particularly a drier vagina. And that’s during sex, but apart from sex you can use a moisturizer, many of which are designed to replace the pH. It’s a little bit more of an acid, mild acid to keep the pH—so, it’s more acid, 4.5, and that keeps the healthy bacteria from staying around and not getting an overgrowth of unhealthy bacteria.
That doesn’t work for everybody, though, and after that we would move to hormonal topical treatment. And the only FDA-approved ones have estrogen, and these are very different from the estrogens that you take by mouth. There is one that’s designed to take by mouth. But the topical estrogens are creams, Estrace, Premarin, and there’s a tablet called Vagifem, and then there’s a ring Estring that stays in for three months and, generally, the partner can’t feel it. That just releases daily estrogen for three months. Now that is all FDA-approved and the doses are so low that there really is not any significant cancer, blood clot or heart disease risk for that. There are no FDA-approved treatment options for testosterone. I know that many people find that helpful and they have to get through compounding pharmacies. We just have to find someone who is monitoring that because if you do absorb too much testosterone, not only can the clitoris grow but then you can get more hair in unwanted places and balding and acne and maybe some heart issues from that, or lipid issues.
Melanie: I think another issue is libido and desire. We seem to go up and down in our lives with that, and men, of course, they have Viagra and they have all these things and, boy, they tout that stuff, but the women they came up with that female Viagra, which is not really that. So, speak about women and desire and libido and how we can ramp that up a little bit.
Dr. Iglesia: There’s a lot of things that go into desire, and the new Flibanserin, which has been touted as the female Viagra, you’re right, Melanie, that isn’t for everybody and doesn’t help, and you can’t drink alcohol, for one, with it. But, it is only FDA approved for women who are premenopausal. It’s not actually not FDA approved for people who are postmenopausal, and we don’t have any FDA approved drugs. And some people feel that testosterone levels, men have Low T, women can suffer from Low T, but there’s a lot of things that go into desire, just in terms of the way women feel about their bodies. I think there’s a lot of concern about body image. I think that some changes that can occur in the architecture of the vagina, particular after you’ve had children. It takes longer to have orgasm, maybe you don’t feel as much, and they’re just feeling very different about their bodies, less confident. And then, there are relationship issues. In addition to that, there’s menopause. I mean, we have the women and we have 30% of them by the time they’re over 50 have dry vaginas. Well, 50% men over 50 have erectile dysfunction, and 60% over 60, and 70% over 70, so there could be some relationship issues and some performance issues on the partner side, and this is assuming heterosexual relationship, obviously.
Melanie: So, what do you tell couples and/or women every single day, Dr. Iglesia, about ways to combat some of these libido issues, body image issues, all of these things? With men it could even be prostate issues.
Dr. Iglesia: Yes, you have to change it up. I mean, I’m not going to say personally, but I have been married to the same guy for now 23 years, and you can’t be doing the same thing. You’ve got to change up. Everybody’s got to change their game. I would say change the location, change the time of day, get some toys in there. There are so many good ones that are out there now. These Lelo vibrators, and then they have these new cock rings, and there’s just a lot of new things that you can experiment with. It may take a little bit longer because blood flow is going there, but now you can use that little Gigi vibrator right on the clitoris. And now, we have special enhancers and arousers just specifically designed to bring more blood flow to that vital area. So, change it up. Read the Kama Sutra, look at different positions, start doing other fun things together to revitalize your relationship. I have to say, at this point in our life, and I have children and they’re grown, you really have to have invested in that relationship with your partner. And, if there are issues, I find that referring out to a sex therapist or couples therapy, making sure that everything is working, just in terms of blood flow and blood pressure and checking on meds that could have a negative impact. Anti-depressants can have a pretty significant impact negatively towards women’s drive and even arousal and some of the blood pressure medicines, in particular, as well. So you need a pretty comprehensive evaluation that can’t be done during your regular routine annual check-up when you’re getting your mammogram, and your breast, and your pap smear, if it happens to be that time. You have to have a separate exam and you’re got to make this priority. It’s nice, I think, when couples come in, whether they be male-female, female-female, whatever, just to talk about some of the issues.
Melanie: What absolutely great advice. Just wrap it up for us, Dr. Iglesia, with your best advice, as couples come to you or women come to you with questions about these myths and misconceptions about sex as it gets into the ages.
Dr. Iglesia: I would say don’t give up. If it’s something that’s really bothering you and really bothering your partner and you really want to make improvements, don’t listen to a gynecologist that says, “Well, what do you expect, Melanie, you’re getting older, and this is what happens.” You don’t have to suck it up. You can divorce your gynecologist. You can see a specialist and someone who’s going to validate these concerns and maybe offer a very thorough evaluation, give you the appropriate referrals, give you the permission to and some advice on other things to try because it’s really a whole new world order and we don’t have to settle for sandpaper sex. We don’t have to settle for lack of arousal. I think you can resume that zest and your drive, and you can maintain it, and it’s totally possible.
Melanie: Thank you so much. What an amazing guest you are, Dr. Iglesia. Thank you so much for being with us today. You’re listening to Medical Intel with MedStar Washington Hospital Center. For more information you can go to medstarwashington.org. That’s medstarwashington.org .This is Melanie Cole. Thanks for listening.