Why Sex MattersHere’s an anti-aging treatment that’s more fun than Botox: sex! Some healthy recreation between the sheets can actually help you look and feel younger. It’s good for your heart; it aids sleep; it can even ease menopause symptoms. Well, that’s great, you say — but what if you can’t get no satisfaction? Hormonal changes, relationship difficulties, and the constant specter of stress can make good sex more elusive in midlife than ever before. Here, five top experts on women’s health talk candidly about the bedroom issues we most often face and what you can do to heat up your sex life.The expert: Marianne Brandon, PhD, sex therapist and coauthor of Reclaiming Desire: 4 Keys to Finding Your Lost LibidoWhy is it important to maintain a healthy sex life? Brandon: It’s about much more than the physical experience of sex; it’s about living fully. When we allow ourselves to completely experience pleasure, it helps us feel awake and alive. So sex is an incredibly important anti-aging technique.If a woman feels that she’s not as sexual as she used to be, what’s the first thing she should do?Brandon: Use it as an opportunity to further her own sexual evolution. Women develop a certain understanding of who they are sexually when they’re in their 20s and then go wrong by believing they have to be just like that throughout life. It’s so not true! We don’t expect ourselves to like the same types of food or music at 45 that we did at 25, and it’s the same with sex. Ask yourself questions such as, "I used to like being touched this way, but how do I like to be touched now?"How can a woman learn to feel more sensual?Brandon: Most of us operate solely on intellect these days, but the more you think, the less you’re feeling in your body, which is essential for sensuality. I give clients mini workshops in which they explore the five senses, to pull themselves out of their brains and into their bodies. For one week, focus on one sense fully throughout each day. During the taste week, really examine the texture and taste of food. During the scent week, light incense or candles and wear perfume. Another idea is to think of a woman who manifests sensuality — like Ellen Barkin. Imagine what it feels like to be her, and then practice at it. You can practice while you’re washing the dishes or getting dressed for work, and the more you do it, the more natural it will feel. Remember, sensuality doesn’t just happen; you have to cultivate it, just like intelligence, athleticism, or any other aspect of yourself.How do you access your sensual side if you have a houseful of kids or you’re working overtime to run a business?Brandon: You can do it in a way that your kids or your employees will never pick up on. Buy a cashmere blanket and curl up in it while you watch television. Buy yourself wonderful chocolates and eat a piece slowly for dessert. Pay attention to your body every day by exercising: dance, yoga, even just stretching helps you get more in tune with your physical self. Sensuality should be a general part of life, not something you save for Friday night.What’s a good way to spice up a stale sexual relationship?Brandon: Try slowing everything down. Think of enjoying it like a meal during which you notice every aspect of the experience. Or do what I call taking your partner to sex school. Make love to your partner exactly the way you want him to make love to you — approach him, look at him, and touch him the way you want him to approach, look at, and touch you. If that’s outside your comfort zone, find a sex scene in a movie where the woman is treated a certain way and ask your partner to watch it with you. He’ll get the point.Why a Woman’s Sex Drive Is ComplicatedThe expert: Joann Pinkerton, MD, president-elect of the North American Menopause Society and director of the Midlife Health Center at the University of Virginia in CharlottesvilleWhat is it about being over 40 that can make sex go less smoothly?Pinkerton: Perimenopause causes a host of hormonal fluctuations that can contribute to libido problems. This time of life is sometimes worse than menopause because hormone levels can be all over the place: Your levels of estrogen and progesterone can fluctuate widely — sometimes going much higher or lower than before perimenopause. Testosterone, largely responsible for your sex drive, tends to decline in your 40s, around the same time that perimenopause begins. Then, in menopause, your estrogen level usually falls steadily, which, along with a lower level of testosterone, lessens desire further. That said, hormones aren’t the whole story. This may be a significantly stressful time in our lives. Our careers may be at their busy and time-consuming peaks. We may have concerns about our children. Our own parents may be failing and need more care. Any of these things can extinguish the libido’s pilot light.The upside is that simple lifestyle changes can help. Just getting regular exercise can relieve stress and hormonal mood swings and give you energy for the things that are important to you, like sex.Why is it that women seem to experience the lion’s share of libido problems?Pinkerton: Women are complex — much more so than men in this arena. When patients ask "What can you do to fix my libido?" my response is that it’s complicated. We have to look at hormonal status, general health, relationship status and stress, to find out what’s going on.Is it common not to seek out sex the way you used to?Pinkerton: Very. As women age, they often find that they stop having the kind of everyday sexual urges they used to have. It doesn’t have to be a problem; you can redefine what successful sex is to fit your own and your partner’s wants now. In your 20s, such sex may have meant simply getting aroused and having an orgasm. Now it might be more intimate: giving massages or stimulating each other with or without an orgasm. What’s important to think about if you’re dating? Pinkerton: STDs. You have to use a condom, which surprises a lot of my patients. Women at this age are more at risk for herpes and HPV than younger women are. You also have to think about pregnancy prevention. The next-highest unintended pregnancy rate after teenagers’ is actually that of women in their 40s.What if you have kids at home? Finding time to be intimate can be difficult.Pinkerton: Morning is a great time. The house is quiet, and your sex drive is high because testosterone levels are at their peak in the morning. If you have a teenager who goes out until his midnight curfew, maybe make love at seven in the evening. Or try for later in the weekend if you’re too exhausted on Friday night.Low Libido? Blame AgingThe expert: Mary Jane Minkin, MD, clinical professor of ob-gyn at Yale and author of a Woman’s Guide to Menopause & PerimenopauseWhich symptoms indicate that hormone changes are causing a low libido?Minkin: Vaginal dryness or pain during intercourse. Before I do any fancy workups on a patient who’s experiencing these problems, I prescribe a vaginal estrogen cream, which you apply directly to the labia. That solves it for many women. Just about anyone — even breast cancer patients — can use estrogen cream.Now, let’s say we fix the dryness or pain, but the woman still has no interest and she knows it isn’t a lifestyle or a relationship issue. We’ll test her hormone levels, and then we might try systemic estrogen in pill form or testosterone. Unfortunately, in the United States we don’t have an FDA-approved testosterone for women, so I’ll do an off-label prescription of a very small dose of the type approved for men or try a testosterone cream that can be applied to the thigh or labia. This increases blood flow to the genitals, aiding arousal. There are a few adverse side effects with testosterone — like increased facial hair and acne — but with a small dose, it’s not a big deal. I had one patient call me years ago to tell me that she was noticing a few stray facial hairs after starting testosterone. I said, "Okay, we’ll just lower the dose." I’ll never forget the tone of her voice when she said, "No, no, we won’t!" The effects were worth the slight downside. With any of these treatments, I tell patients to try them for three months. If they don’t work, we reevaluate.What other age-related health issues cause libido problems?Minkin: As we get older, we take more meds, and our partners do too. Some drugs do a very dirty job on sex drive. The classic is SSRI antidepressants, such as Prozac. Cymbalta — a newer antidepressant, called an SNRI — may have less of an effect, which is the case with Wellbutrin, also not an SSRI. If you really like your SSRI but don’t like the sexual side effects, some docs add a prescription for a small dose of Wellbutrin to solve the problem. Drugs for high blood pressure are notorious for decreasing erectile performance, and they can also block orgasmic response in women. Your doctor can switch your medication. Hypothyroidism, which is a huge problem for women in this age group, is subtle and is associated with decreased sexual response. Ask your doctor for a TSH [thyroid-stimulating hormone] screening test, which we now recommend for all women over 50. It can be performed in her office.Okay, so let’s say the problem isn’t health-related but has to do with getting used to the idea of aging.Minkin: What you think of yourself is crucial. As my good friend Dr. Ruth says, "The most important organ in the body for sexuality is between the ears, not between the legs." Many 40-plus women feel they’re not as attractive as they once were, but if you ask me, it’s bullshit. The young, immature starlets on their third trip to rehab are not so alluring, really. The interesting thing is that when we research societies where age is valued, women have fewer menopausal symptoms, like hot flashes, so there’s something to be said for appreciating your age.We so often talk about over-40 sex being problematic, but aren’t some women having the best sex of their lives during this time?Minkin: Absolutely. Menopause can be liberating, because you no longer have to worry about getting pregnant or deal with painful conditions like endometriosis and fibroids. For a lot of people, menopause turns out to be a blessing for all its sexual benefits. Is Sex Better at 25 or 45?The expert: Laura Berman, PhD, author of The Passion Prescription: Ten Weeks to Your Best Sex — Ever!Why is sex so healthy for us? Berman: There are several reasons. It boosts the immune system and combats depression, and, because it’s exercise, it promotes cardiovascular blood flow. You burn up to 50 calories during 30 minutes of sex, as compared to about 35 calories sitting and reading for 30 minutes. It also increases your genital blood flow, which helps keep your sexual response healthy. It’s the "use it or lose it" phenomenon: Physiologically and clinically, we’ve found that the more often you have sex, the more you’ll respond sexually and the more "in the mood" you’ll be.Why is sex essential for a good relationship?Berman: The more sexual you are as a couple, the better off you’ll be. We’ve found in our national research that the number-one predictor for emotional connectedness in a relationship is the level of sexual satisfaction of the couple. You acquire a sense of closeness with your partner by having sex. It creates an intimate, romantic world for just the two of you. Can sex help relieve menopause symptoms? Berman: Yes. The endorphins sex and orgasms release can help with moodiness and sleeplessness.Is sex better at 25 or 45?Berman: Here’s the thing: A woman in her 20s may be physically in her prime, but that’s just one small part of her sexual response and experience. From what I’ve seen, older women are more confident and empowered, and they feel more comfortable being uninhibited — all of which gives them a huge sexual advantage over the twenty-somethings. It’s good news all around: A doctor can often fix the physiological issues that women over 40 may be dealing with, and the emotional characteristics that older women possess are really the essential ingredient for a great sex life.What if your partner has erectile dysfunction, or ED? Berman: Men who have ED typically shut down sexually. They won’t hold hands or be romantic because they associate those things with the lead-up to sex and they don’t want to face potential failure. So do make an effort to talk about it as a problem you can tackle together, which may lessen his anxiety. Offer to go to the doctor’s appointment with him, even if you just sit in the waiting room. Once he’s been treated, you’ll likely have an increase in your sex drive too. We know that the partners of successfully treated men also get a lift, because men who are more sexually confident reach out to their partners more, engage in more foreplay and have less anxiety, which lessens their partners’ anxiety as well.What’s crucial is to approach treatment as a team. Your partner needs to understand that just because he took his pill before dinner and he has an erection by the end of the meal, it doesn’t mean you’re ready to jump into bed. In other words, you don’t need to "use" the erection as soon as it happens. Viagra, in particular, has a 12-hour half-life, so he can get the erection, it can soften during foreplay, and then he’ll get the erection back.What are some ways to achieve a better orgasm?Berman: Decreased vaginal blood flow, which can often be helped by hormone therapy, is one reason midlife women experience less genital sensation or have less intense orgasms. Vibrators can help, and I actually prescribe them to my patients to help them reach different goals. For example, with a mini massager, you can learn to stimulate orgasm by varying the pressure on different areas of your genitals, or you can learn how to achieve orgasm more easily by placing it on your clitoral area, between you and your partner, while you’re having intercourse. Weakening of the pelvic floor muscles causes less intense orgasms too. Childbirth is the most common culprit; women who’ve had several vaginal births have the most trouble, but even women who’ve had cesarean births can experience it. Regular Kegel exercises, in which you contract your vaginal muscles as if you’re stopping the flow of urine, can help.How to Feel SexierThe expert: Christiane Northrup, MD, ob-gyn in Yarmouth, Maine, and author of The Wisdom of MenopauseWhy do so many over-40 women simply find sex less appealing? Northrup: What’s really happening with women’s libidos after 40 is that there’s this hormonal shift that allows unresolved anger, if you have it, to show itself. You’re mad at yourself for allowing your family to put you last, you’re irritable at work, and none of these sentiments help you feel sexy. The good news is that these changes, in my opinion, are actually designed for women to clean up their pasts and give birth to their best selves.Is this a universal problem? Do all women feel less sexual as they age?Northrup: No, which is why we can’t say that the menopausal transition is solely responsible for decreased sex drive. Boredom in relationships is a real issue: We know from research that the number-one predictor of a really good sex life at midlife is a new partner. With somebody new, you don’t have all that history together. How can we learn to feel sexier?Northrup: Women at midlife need to be able to see themselves as the ideal sexual woman no matter whether they’re single, married, gay, or straight. Find out what turns you on by making pleasure a priority in your life. Let me get completely graphic: Set aside several times a week for self-pleasuring. Act as if a rock star (or whoever does it for you) is coming to your home and you are going to seduce him or her. Put fresh flowers in the bedroom, make the sheets all sexy flesh tones or red silk — whatever you like. Turn your bedroom into a boudoir and practice. The exercise will help you fall in love with yourself.It’s important to learn to communicate what we want from our partners, isn’t it? Northrup: It’s essential. We are taught backward: Men feel they should know what to do during sex, but it’s actually a woman’s job to decide what she wants and tell her mate how to provide it. That’s why it’s so good that we’re seeing the interest in classes like belly dancing and pole dancing — things that help you find your inner erotic creature, which is not at all about being sexy for a man. Women are finding that their ability to be seductive and experience pleasure is unlimited. It’s very exciting!More from Your Over-40 Health Guide Originally published in MORE magazine, May 2008.