Sex Over 50: In the Viagra Age, Are Women Left Behind?

The commercial that appeared on network stations in the 90's introducing Viagra to the American public was a memorable advertising event. Not only was it the first time in history that erectile dysfunction (ED) was discussed in a public forum, but our very own Bob Dole was the man who brought the topic into living rooms everywhere.

Mr. Dole was informing us that a new pill called Viagra was now available by prescription and would do the trick for guys that couldn't get it up. What was also noteworthy was Pfizer's extraordinary marketing savvy and determination and that they had likely hit pay-dirt now with their pill that could restore men's sexual potency. While all this was useful information for me as a sexuality counselor and GYN practitioner, I also took note of what the commercial didn't tell me; how were the women managing men's restored sexual prowess?

Dole's predicament came as no real surprise. Complete erectile dysfunction has a probable occurrence rate of approximately 15 percent in men 40-70 years of age. (Note that this statistic doesn't include the rate of intermittent ED.) Causes of ED are most often related to chronic diseases common in aging men such as diabetes, high blood pressure, and heart disease that have predictable deleterious impact on blood vessels, including those in the penis. ED can also be a side-effect of various medications. Meanwhile, approximately 40 percent of post-menopausal women (average age of menopause is 52) will experience significant changes in the health of their vulvar and vaginal tissue which can interfere with their enjoyment of any penetrative sex.

These changes include decreased elasticity and lubrication, thinning of the tissue and constriction of the vaginal opening. Without reparative therapy, these changes can make intercourse about as comfortable as chewing glass. Oops! Pfizer and the practitioners who were writing prescriptions for Viagra forgot: women have health issues and needs too when it comes to aging, vaginal penetration, and their genital preparedness!

While internists and urologists were thrilled to be able to relieve the suffering of their flaccid and forlorn male patients, the Hippocratic oath: "Do No Harm" fell by the wayside when it came to their patients' partners who were now -- by proxy -- being harmed by their newly functioning and very enthusiastic husbands.

When it comes to women's genital health, the sorry facts are this; fewer than 25 percent of post-menopausal women who experience significant genital changes receive the care they need to live more comfortably with these changes (1). They're often essentially disregarded in the decision of whether or not her husband's restored ability for intercourse was something she could accommodate.

What I see most often in my GYN practice is that women and their male partners are totally uninformed about the common changes that occur in women's genitals once the circulating levels of estrogen have substantially declined as they do post menopause. In many cases women are expected to simply grin and bear it. It seems that women's genital health is a post script to the practitioners treating the men who want to have sex with them.

In order for the majority of post-menopausal women to enjoy penetrative sex (or genital stimulation), adequate lubrication with silicone based or water soluble lubricants are a must with every sexual event -- self-pleasuring or partnered sex. These products are assistive; they cool the skin and reduce friction but they're not truly therapeutic.

Topical estrogen treatments, in the form of creams, vaginal suppositories, or an indwelling ring that stays in the vagina are options for administering estrogen where it's needed -- in the vagina and on the vulva. The use of these products in women with a history of breast cancer is controversial. All of these products are by prescription only and finding a women's health care provider who is well versed in their use and value is the most important thing. In addition, expect to use them long-term; additional calcium and Vitamin D for life-long bone health and topical estrogen for life-long genital health.

If you're a woman who can't use estrogen in any form, try Vitamin E vaginal suppositories and Vitamin E cream externally on vulvar tissue. These products are available over the counter without a prescription. They are not as therapeutic, but are definitely better than nothing. I often will suggest a combination of these products to treat both the vulvar tissue and the vagina. This maximizes women's comfort and therefore their contentment when it comes to sexual activity.

Sadly, women themselves are reticent to complain about these problems and even worse, many of my OB/GYN colleagues simply don't ask. As my patients have said themselves when I have noted this: "Why didn't anyone else talk to me about this before?"

(1) CM Lynch, "Atrophic Vaginitis Diagnosis and Treatment Options": Female Patient. 2010: 35 (7) 16-19