Whither Desire?

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By Nancy Wartik || Crosspost with The AARP Magazine \\ November & December 2007

The lust is gone. The fires are out. What happened? Is there anything you can do to rekindle love’s passion?

*Names of interviewees and their partners have been changed for privacy.

When she was in her 30s, Margaret Monaghan* ended a relationship because her boyfriend liked sex less than she did. “He thought sex once a week was more than enough,” she recalls.

Sex then was a vital part of her life, says Margaret, 60, who teaches business communications at a North Carolina university. When she met her current partner, David, 57, some 16 years ago, things were frisky at the start. But in her late 40s, menopause hit and Margaret’s libido fizzled.

“I wasn’t looking forward to having sex as much,” she says. “It was, ‘If we do it, we do it; if we don’t, we don’t.’ And that started to become a problem, because David is someone for whom sex is very important.”

Hormone replacement therapy (HRT) helped with her hot flashes and mood swings but not her libido. Margaret tried testosterone, sometimes prescribed for off-label use (i.e., not its FDA-approved use) as a libido booster for women. It didn’t help. Meanwhile, she and David argued over Margaret’s sexual indifference. “He’d say, ‘Okay, does this mean you don’t love me—do you want to break up?’ ” she recalls. “I felt like I was letting him down, because I wasn’t the person I had been.”

For many women nearing or past the half-century mark, the story will sound familiar. Sex, once a lusty, reliable pleasure, now falls somewhere between “Walk Fido” and “Water the ficus plant” on the household to-do list. A 2006 study in the journal Menopause found that nearly a third of partnered women between 50 and 70 have little or no sex drive, and many have trouble feeling aroused. Moreover, 33 percent of these women who had entered menopause naturally, and 44 percent who had had hysterectomies, said they were upset about their lack of interest in sex. “It was very strange—like losing a part of my identity,” says 74-year-old Daisy Graham, a retired New York State professor, who lost her once-healthy sex drive about five years ago. Even worse, Daisy says, was the devastating impact on her partner of ten years, Richard, 77. “It was a major, painful thing for him, and I felt terrible.”

For Daisy, Margaret, and millions of other women upset about the vanishing of their sexual selves, quick-fix solutions elude them—and the reasons can be as confounding as the loss of the desire itself. While many men can find an easy boost in the decade-old erectile dysfunction drug Viagra (and now its progeny, Cialis and Levitra), women have no equivalent fix for their different, but equally common, sexual problem: loss of desire. In recent years the pharmaceutical industry has been in search of new treatments (see “Will There Ever Be a Pink Viagra?”), but progress is slow. And despite the success of testosterone for some women, there’s little likelihood of seeing a one-size-fits-all libido booster soon, if ever. Still, experts say, that doesn’t mean 50-plus women can’t do a lot to ratchet up their sexual pleasure. A flurry of new research on women’s sexuality has led to lots of fresh thinking about what couples can do to get back the passion—indeed, about why women lose their desire in the first place.

No one knows exactly why some women stop feeling the urge. True, levels of estrogen, the main female sex hormone, decline at menopause, triggering physical changes that for some women make sex a turnoff. Testosterone, the “male” hormone that fuels libido and that women’s bodies manufacture in small amounts, drops, too. Yet the problem can’t be pinned totally on hormones, because plenty of women enjoy themselves in bed years after hormone supplies have dwindled. Take Hallie Delsen, an 82-year-old mother of three who lives in Hastings-on-Hudson, New York. Married 54 years to her husband, Bill, 83, she says sex now is better than ever. “It’s knowing what works, I suppose,” Hallie says. “I’m always willing to experiment.”

Many aren’t so lucky. Unlike for men, whose sex drive tends to be more clearly related to having all the parts in working order, a woman’s drive is typically more complicated. “It’s not as linked to plumbing,” says Edward Laumann, Ph.D., a University of Chicago sociologist who specializes in human sexuality. “The system isn’t orchestrated so that if you push a lever, everything works.” For example, he adds, “it’s very clear that women’s sex lives are highly affected by the quality of their relationship with a partner.”

It’s very clear that women’s sex lives are highly affected by the quality of their relationship with a partner.

A slew of midlife issues—many of them not at all related to sexuality—can also interfere with sex drive. Health problems, which may get worse as women get older, can squelch erotic feelings, as can the side effects of medications to control those problems. And often, at menopause, many women confront a life- disrupting series of transitions—empty nests, parent deaths, messy divorces, stalled careers—that leave them feeling anything but erotic. “It can be a time of extraordinary demands,” says Pepper Schwartz, Ph.D., a sociologist at the University of Washington in Seattle and author of Prime: Adventures and Advice on Sex, Love and the Sensual Years (Collins, 2007). “It’s often a turning point. You’ve been doing your work for a lifetime, and maybe you need new challenges. Maybe your marriage is stable but boring, or your kids are unhappy, and now your body is betraying you.”

One may reasonably ask, if I’m not interested in sex, why try? Why not simply accept the person I’ve become? And, in fact, if you’re not unhappy and not having relationship issues over sex, some experts argue it may be the way to go. “All women are not the same,” says Leonore Tiefer, Ph.D., a psychologist at New York University School of Medicine, “and there’s no one model for women’s sexuality.” But for women who consider sex a vital part of their lives and long for a return to it, a strong case can be made for giving it a go.

For one thing, there’s your health to consider. Quite a few studies show a strong correlation between staying sexual and staying healthy—and even between sex and longevity, Schwartz says: “You can almost tell who’s still having sex from the positive energy they project. The truth is that we’re sexual way into old age, and I think it’s really important to keep that part of you alive.”

Regaining that loving feeling is not difficult, adds Sandra R. Leiblum, Ph.D., director of the Center for Sexual and Relationship Health at the University of Medicine and Dentistry of New Jersey–Robert Wood Johnson Medical School in Piscataway, New Jersey. “You only need to give up if you want to give up,” she says. “There are lots of ways to be sexual.”

The first order of business is to find a doctor who can identify whether there is something physically wrong. Finding an empathetic physician is not as easy as it sounds. Jennifer Miller, 51, a New York State mother of two, discovered that after she had a hysterectomy that KO’d her sex drive. “I saw five or six doctors, and nobody heard me. They were embarrassed talking to me,” she says. “I couldn’t believe this was the boomer generation, where everybody talked about a healthy, happy sex life. Weren’t we once all living together in coed dorms, having a great time?”

The reticence on the part of the medical profession is not unusual, says Sharon D. Malone, M.D., associate clinical professor at George Washington University, whose private practice focuses on pre- and postmenopausal issues. “Even among OB-GYNs, a lot feel uncomfortable talking about this,” she says. “And a lot of women feel uncomfortable bringing it up. They think, ‘It’s just me,’ and suffer in silence.”

Jennifer eventually found a doctor who first prescribed Viagra, which is sometimes tried for women—it only gave her a headache—then did blood tests that revealed she had virtually no testosterone in her body. The two talked through the possible side effects of a low-dose testosterone cream—things like hair growth on the face—then took a chance. “We just can’t believe the difference,” says Jennifer, who notes that she and her husband have been having sex several times a week ever since. “It’s just about the two of us now; it’s not about hard work anymore.”

Thyroid disorders, depression, and diabetes can snuff libido, too, as can medications, including many antidepressants and some medications for high blood pressure. Menopause can trigger symptoms that are mood killers in themselves. “Postmenopausal women can be irritable,” Malone says. “They can have night sweats, insomnia, mood swings, and vaginal dryness that makes sex uncomfortable or painful. And a sleepy, dry, cranky woman is not very sexual.”

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Will There Ever Be a Pink Viagra?
By Nancy Wartik, November & December 2007

While women wait, many experiment with alternatives. Are they safe?

It’s a holy grail of the pharmaceutical industry: a wonder drug that could boost women’s waning libidos the way Viagra gives a boost to men with erectile dysfunction. In search of “pink Viagra,” drug companies have developed pills, creams, patches, and (believe it or not) clitoral pumps. But no magic formula seems on the horizon.

“There’s research going on, and a couple of things look quite promising,” says Sandra R. Leiblum, Ph.D., director of the Center for Sexual and Relationship Health at the UMDNJ–Robert Wood Johnson Medical School in Piscataway, New Jersey. “But for so many women, emotional and interpersonal factors account for a lot of sexual enthusiasm.”

Still, by talking to your doctor, you may find that a prescription or over-the-counter drug can jump-start your limp libido. Possible candidates:

Estrogen replacement therapy (ERT) Postmenopausal women who take estrogen, alone or with the hormone progestin, generally have fewer symptoms, such as vaginal dryness or pain, that make sex unpleasant; it’s not clear if ERT increases desire, as such. But recent studies linking ERT to increased cancer, stroke, or heart disease risk in some users mean you should discuss your medical history carefully with your doctor before starting this treatment.

Vaginal estrogen creams also relieve dryness or pain, at lower estrogen doses.

Testosterone Three years ago the FDA rejected Intrinsa, Procter & Gamble’s low-dose testosterone patch, which seemed slated to become the first prescription treatment for so-called female sexual dysfunction. Though it dashed some experts’ hopes for a drug shown to rekindle desire in a significant number of postmenopausal women, others applauded the FDA, noting, among other things, that studies of the drug had lasted only six months, leaving its long-term safety open to question. Research continues, though, and some doctors still prescribe testosterone off-label. But it’s hard to predict for which users the medication will work. It can raise cholesterol levels, so regular blood tests are a must.

Viagra It’s blue rather than pink, because it’s the same pill men take. For a small group of women, including some who are on libido-killing antidepressants such as Prozac, Viagra (generic name: sildenafil) may improve sex, perhaps because it increases blood flow to the genitals and increases vaginal lubrication. The drug doesn’t increase desire itself, however.

Alternative remedies Over-the-counter libido boosters, among them a variety of supplements and creams, are mostly unproven, so consult your doctor before trying them. But two products that have gotten scientific scrutiny are DHEA (the hormone dehydroepiandrosterone, secreted by the adrenal glands and converted in the body to estrogen and testosterone) and ArginMax, both sold in drug- and health food stores.

A small number of studies suggest DHEA can increase libido after menopause. But it doesn’t require FDA approval, and many experts have concerns about women taking a supplement that potentially raises hormone levels.

ArginMax contains the amino acid L-arginine, plus ginseng, ginkgo biloba, other herbs, and vitamins. One study of 77 women ages 22 to 71 found ArginMax tended to increase sexual desire and satisfaction in users.

Bremelanotide This medication, currently being tested as a nasal spray with both sexes, acts on the brain’s hypothalamus, which helps regulate sexuality. In a small study of postmenopausal women, bremelanotide got the majority of users hot and bothered. Should it win FDA approval, you might someday be able to sniff your way to better sex.

Feeling this way need not be cause for despair. Each of these problems is treatable. In the growing new field of “sexual medicine,” once mainly focused on male dysfunction, a number of doctors and psychologists are specializing in the treatment of female problems. (To find a center devoted to female sexual health, search the Web for a city name along with sexual health or sexual medicine. Or to find a knowledgeable doctor, check local teaching hospitals or call an area gynecological practice and ask if anyone specializes in postmenopausal patients.)

Once a woman begins addressing the physical problems she may have, experts say, she may also need to shift her attitude and expectations about sex, and rethink what it means to be turned on at age 50-plus. “It’s a different sexuality,” explains Esther Perel, a New York City marriage and family therapist and author of Mating in Captivity: Unlocking Erotic Intelligence (Harper Paperbacks, 2007). “You may not feel that tingle of arousal you used to always feel before you start,” she says. Rather, it’s trusting that the feeling of pleasure will come once sexual play begins. “The motivations come from a much broader palette. It’s a shared complicity, a feeling of wanting to please your partner and knowing you’ll feel good afterward.”

Also, it helps to tune in to the way popular culture insinuates itself into your expectations about sex. “The movies show us that people are overcome with passion, and sex takes them over,” Perel says. But, face it: sex isn’t always like that, particularly when you’ve been staring at the same person over morning coffee for 30 years. “If you have the idea that desire comes only in the form of fireworks, you’ll be at a loss,” Perel says.

So what do you do if low libido has more to do with boredom than the changing body? One solution is to find courage to step outside the sexual safe zone. “Women have to be willing to try things they haven’t before—a new place, a new sexual script,” says Leiblum, who is also the coauthor of Getting the Sex You Want (ASJA Press, 2003). The anxiety this creates can be erotic in itself. “What is arousing is the nervous excitement and mystery you feel when you don’t know what quite to expect,” she says.

Perel says she counsels people to seek out novelty. “I’ll tell a woman, ‘In the next two weeks I’d like you to approach him once in a way you’ve never done before,’ ” she says. “ ‘Think of a time when you were particularly sexually daring, and imagine yourself bringing some of that assertiveness to him. Go to a clothing store and don’t buy what you’re used to buying—get something that brings out a whole other side of you.’ ”

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Sexual Awakenings
By Nancy Wartik, November & December 2007

How to regain an active sex life at 50 and beyond

Change your mind Not feeling aroused? Say yes to sex even when you’re not in the mood. Often the excitement and pleasure will come once the erotic games begin.

Assemble a good team If you suspect your libido problems may be medical in nature, you may need to shop around for just the right doctor to help you. Don’t settle for a physician who seems uncomfortable with the topic or tries to minimize its importance.

A knowledgeable doctor should ask lots of questions and listen closely: “This isn’t a quick-fix problem,” says Sharon D. Malone, M.D. “It requires patience. If a doctor rushes out of the room after you bring up the issue, find someone else.”

Breach your security zone Try something novel—sensual activities that make you just a little nervous with anticipation. You can get aroused simply by taking the challenge.

Confront the fears Put those worrisome couples issues on the table, and, if necessary, begin meeting with a therapist. Anger, hurt, and resentment can all get in the way of intimacy.

Set a schedule Sex at least once every two weeks will keep the blood flowing in all the right places—which can make sex more appealing in itself. But don’t wait for things to just happen. Make a date.

Get a workout Regular exercise not only makes you feel better about your body; it can boost sexual satisfaction, too. So hit the treadmill, take a yoga class, lift a few weights. It all adds up.

Actively thinking in a sexual way, Schwartz says, can spur creativity about how to deal with issues such as boredom, and even jump-start that long-overdue promise to yourself to get in shape. And that could be a double win: a University of Vermont study published two years ago found that for women going through menopause, frequent exercise was more strongly linked with whether they were sexually satisfied than how they felt about their appearance or even than their testosterone levels.

But women shouldn’t wait until they’ve shed those few extra pounds or revved up their fitness regimen. Schwartz recommends a healthy dose of deception in the bedroom. “Get a dimmer,” she says. “Give yourself soft lights. Get colored lights, candles, all the things that make you feel romantic.”

Conventional wisdom among sex therapists is that you should meet between the sheets at least every two weeks. “Part of the myth of spontaneity,” Perel says, “is that sex just happens, unprompted, rather than that it’s something that’s willed. Committed sex is premeditated sex. It’s the opposite of ‘hooking up.’ ”

“With vaginal health, it’s use it or lose it,” says Bat Sheva Marcus, clinical director of the Medical Center for Female Sexuality in Purchase, New York. “At menopause and beyond, you actively need to keep blood flow going in that area. Otherwise it gets dry and painful.” Regular sexual activity, partnered or on your own (think vibrators), can help you stay sexually limber.

All this scheduling and primping can seem like drudgery if a woman is having fundamental problems with her relationship, though. “Sex is always a couples issue,” says Laura Berman, Ph.D., director of the Berman Center, a women’s health center in Chicago, and author of The Passion Prescription (Hyperion, 2006). When one partner desires and the other doesn’t, or if both have lost interest, it can create a vicious cycle of hurt, anger, rejection, and more bad feelings. Berman’s rule of thumb: “If you’ve gone six months with your sex life consistently not working, it’s important to look at what’s happening.”

Talking about this subject openly can be tough. Pick a time when neither of you is angry, and try to approach it nondefensively. One suggestion from Berman: Browse books about sex and mark relevant passages for your partner. Once he’s read them, it can help start a dialogue. Or consider finding a therapist. Visit the websites of the American Association for Marriage and Family Therapy or the American Association of Sexuality Educators, Counselors and Therapists to find one in your area. “There can be so many unspoken messages,” Berman says. “Couples may not know how to talk when things aren’t working.”

Paradoxically, though, working on your sex life as a couple may involve deliberately planning time apart. Perel stresses, for example, that too much closeness can work against passion. Separate diversions, separate outings with friends, even separate vacations, can remind you and your partner that you thrive on your own, and may help rekindle a missing spark.

For Margaret Monaghan and her partner, David, a combination of approaches turned things around. Three years ago they saw a therapist who had them outline what they thought their mate needed to be happy. “I told David, ‘I think you want to have sex once or twice a week and once a month do something special,’ ” Margaret says. “He said, ‘Yup, that’ll do it.’ ”

Having a goal to shoot for helped tremendously, Margaret says, as did a willingness to compromise. “David would probably really like to have sex every day,” she says. “But we’ve created a set of expectations we’re comfortable with. We probably have sex once a week—David calls it meat and potatoes sex. Then once a month there’s dessert or lobster—something special. Fancy lingerie, or role-playing.”

She usually enjoys herself once things get started, Margaret says. But what’s also meaningful: making her partner happy. “I want to be as considerate of David as he is of me,” she says. After all, “it’s a partnership.”

Nancy Wartik is a freelance writer based in New York City.

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