By Emily McCluhan
You’ve lived with this body for 20, 30, 40 years or longer— shouldn’t you know everything about it by now?
But women’s bodies are dynamic as we age— and nowhere is that more apparent than in our reproductive organs. We talk to the experts about how to best care for our areas down there.
“Libido requires a brain-body connection,” says Ellen Barnard, co-owner of A Woman’s Touch, a sex education resource center and sexuality products shop in Madison. Unlike an erection on a man, female arousal is more subtle. If your brain is focused elsewhere, you may not notice your body saying yes to intimacy and sex. Barnard says you may need to learn to get your brain to say yes to sex, even if you don’t feel excited or aroused. It’s a notion called responsive desire. If you know that when you get going, things are going to be fun, safe and pain-free, then learning how to say yes, even when you don’t have that physical feeling, is completely acceptable.
It’s normal when desire declines, especially once the initial passion in a relationship fades and daily distractions set in.
“Breastfeeding, children, health challenges or menopause cause changes in physical arousal to happen. So you might not be able to notice the physical signs that used to signal de- sire. As long as everything is OK—you have no pain, you like your partner, sex is pleasurable—you can choose to say ‘yes’ to your partner. Your brain can lead the way, which can get your body to say, ‘sex will be fun—let’s go!’” says Barnard.
“I tell people to figure out what it is that turns [them] on and deliberately make that happen. Maybe it’s enjoying [their] favorite fantasy, or watching visual erotica [in a] movie or on- line,” says Barnard. “For sure, put it on the calendar and plan a sex date and actively think about it. Send sexy texts back and forth that talk about what [you’ve done together] before, or what you will do. Always make sure the sex you’re having is fun and good—because the way to want more sex is to have good sex.”
Barnard adds, “Desire and sex change all the time. In fact, if you really pay attention, sex is different every time. Adaptation and resilience are the keys to sexual pleasure. It’s not about hormones, or pills or any quick fix.”
Fertility Facts & Contraception Cues
Thanks to a variety of contraception and reproductive technologies, couples have more control than ever over when they start or grow a family. We asked Dr. Eliza Bennett, MD and clinical associate professor with the UW-Madison School of Medicine and Public Health Department of Obstetrics and Gynecology, about key factors that increase the chances of baby-making through our 20s, 30s and 40s, and also how contraception plays a part.
“At any age, the most important things for maintaining fertility are the things we should be doing anyway,” says Bennett. “Not smoking, maintaining a normal or healthy weight, avoiding excessive alcohol intake and exposure to environmental toxins.”
Especially in our 20s, she stresses the importance of keeping the cervix and fallopian tubes healthy by avoiding STIs through the use of barrier contraceptives like condoms. As we age, especially over 35 years old, fertility declines with fewer healthy eggs viable for fertilization. There is also an increase in the chances of maternal complications with pregnancy as we age.
You may have heard the term “geriatric pregnancy” with more frequency these days. That’s because it’s more common for women to have children later in life, in their 30s and 40s, and a geriatric pregnancy refers to a pregnancy in a woman over the age of 35. Of course, this doesn’t mean a woman is geriatric if she’s pregnant at 35—Bennett explains it’s simply a reference to an incremental risk of having a baby with an extra chromosome starting at age 35.
“The majority of women in their late 30s and 40s have completely normal pregnancies,” she reassures.
If you’re in your 20s and you know you eventually want a family but not right now, freezing your eggs is an option to preserve fertility. Women in their 20s and 30s are the best candidates for egg freezing, since eggs are healthier at a younger age. However, know that freezing your eggs and storing them can be expensive— so you’ll want to research and consider your options carefully.
If the idea of caring for a tiny human at any age makes you cringe, Bennett suggests using a long-acting reversible contraceptive (LARC), such as an intrauterine device (IUD) or implant, since they are more effective than short- acting methods like the birth control pill.
She adds, “But you should use a two-pronged approach for pregnancy and STI prevention, especially in your 20s or when you have a new partner or multiple partners. So [that means] an IUD plus a barrier method to protect those tubes and keep them free from infections and STDs—in case you do want to have babies later.”
Bennett notes there are two peaks for unintended pregnancy: women in their 20s, when fertility is high and they either don’t use contraception or rely on less- effective forms of contraception like the pill or condoms, and women in their 40s who think their fertile years are behind them. But just because your fertility has declined, it doesn’t mean it’s gone, says Bennett.
For women over 40, Bennett advises caution when considering contraception with estrogen like the pill because of an increased risk of blood clots, stroke or heart attack. IUDs and implants are progesterone-only and come with lower risks and higher effectiveness.
When family-planning does feel right, all long-acting contraceptives and most short-acting methods stop working immediately, Bennett says—except in some women the injectable Depo-Provera can have a longer effective window.
“If you know you had irregular cycles prior to starting hormonal contraception and want to conceive, consider stopping hormonal contraception and use a barrier method to get a feel for your cycles and the timing of ovulation,” suggests Bennett.
She also points out that LARCs aren’t just for preventing a bun in the oven. They can also lead to lighter or no periods, reduced risk of certain types of cancer, reduced pain from endometriosis and even relief from peri- and post-menopausal symptoms.
Much Ado about Menopause
A quick survey of my 30- and 40-something gal pals provided a chuckle as to how little we knew about menopause, and it made us wonder at what point we should’ve learned about it. We know the menopause horror stories from our female elders about hot flashes and vaginal dryness, but most women likely don’t think about menopause, which is the absence of a menstrual cycle for over six months, in conjunction with several other symptoms (mentioned below), until we’re staring it down. Dr. Julie Schurr, OB-GYN with Physicians for Women—Melius, Schurr & Cardwell, says she typically sees women about menopause when they’re crying uncle. The most surprising takeaway many women may not know is that “the change” (as it’s colloquially called) doesn’t last just a few months, or even a year. “Usually there’s a bell- shaped curve, about four years on either side of 51 years old. On the front end women traditionally begin to experience minor symptoms. Most women just endure it until it reaches a crescendo,” Schurr says.
She points out typical symptoms to look (and feel for) include thinning of the vaginal wall which can equal painful sex, vaginal dryness, hot flashes and changes in your menstrual cycles. There’s also a decrease in blood flow to the genitals and hormone changes as estrogen wanes, which may cause insomnia, migraines, irritability, and dry skin and hair. Barnard adds that staying sexually active during and after menopause can be challenging, due to the dryness and thinning of the vaginal walls. Barnard suggests experimenting with different types of lubricants and even massaging your vulva to keep skin flexible and blood flowing.
“Massage is a key part of that, because it can actually restore your sexual function in the same way that estrogen used to,” notes Barnard. She also says staying active and eating anti- inflammatory foods, such as options within the Mediterranean diet, can assist sexual function.
When that “crescendo” of symptoms occurs that Schurr refers to, she says it may be time to discuss hormone replacement therapy (HRT) and topical estrogens with your doctor. HRT addresses many of those uncomfortable menopause symptoms, but can also help prevent osteoporosis. Pills, creams and skin patches are just a few ways HRT can be administered for balancing out hormones during this time.
However, it should be noted that as with any medication, there are nuances in terms of benefits and drawbacks to HRT. Acording to Schurr, a recent follow-up to a 19-year study called the Women’s Health Initiative provided interesting results related to HRT.
“The data implies that estrogen-only therapy offers protective benefits. But when you take [estrogen-only HRT] and you have a uterus, that ma stimulate the lining of the uterus to become malignant. So, you increase your risk for uterine or endometrial cancer,” she explains.
The study also found that conjugated HRT (methods that combine estrogen and progesterone), reduces the risk of endometrial cancer. But, the study also suggests it increases breast cancer risk during, and even after, the discontinuance of hormone therapy.
“With this new data, we’re really between a rock and a hard place. Our goal is always to [use] the least amount of hormone therapy for the shortest amount of time,” says Schurr, who recommends talking to your gynecologist when you start to notice symptoms of menopause.
Can Sex Delay Menopause?
According to a January 2020 article in Newsweek, a recent study reveals that regularly having sex may be linked to women reaching menopause later. The study’s authors hypothesize that there is an adaptation that has occurred over time where sexual inactivity cues the body to get rid of eggs and stop menstruating, because pregnancy is less likely to occur. And so the opposite, regular sexual activity, may delay menopause.
Of course, menopause is an inevitability for women, and the study notes that “there is no behavioral intervention that will prevent reproductive cessation; nonetheless, these results are an initial indication that menopause timing may be adaptive in response to sexual behavior.”
Yep, You have a Pelvic Floor. So What’s Pelvic Prolapse?
Half of women will experience some degree of pelvic prolapse, yet most women are embarrassed to talk about it. Schurr notes that 90% of prolapse is a result of vaginal childbirth, but most often women don’t notice the symptoms until the vaginal walls start to thin and the muscles weaken as estrogen declines with menopause.
“That’s when you might notice it feels like you’re sitting on a ball or you feel something protruding from your vagina. Often bladder function changes or bowel movements become difficult,” she says.
This is all due to the uterus, or another pelvic organ like the bladder or rectum, protruding into the vaginal canal, or even out of it. Kegel exercises may help keep the pelvic floor strong, but one option your doctor may recommend is a pessary, a removable device that can be inserted into the vagina to hold the uterus in place. Otherwise, Schurr says some women opt for surgical correction for prolapse.
Can anything be done to prevent prolapse? Not much, according to Schurr.
“Maintaining a healthy weight can help, but if you’ve given birth vaginally, your ligaments and fascia will either be able to withstand the pressure or not,” she says.
Ask the Pro: Pelvic Floor 101
Ellen Barnard, co-owner of A Woman’s Touch, explains the complicated issue of weak and tight pelvic floor muscles.
How do I know I have weak pelvic floor muscles?
I always describe weak pelvic floor muscles as floppy fettuccine. There are 14 muscles that make up the pelvic floor. If you’ve got something that’s really floppy there’s no tension. So a lot of times we’ll see a combination of leaking urine, but also orgasms fade away.
So if I’m leaking urine and having weak orgasms, I should just do Kegel exercises all the time, right?
Wrong. Kegel exercises can help strengthen weak pelvic floor muscles if done correctly. Often I hear from women that they’ve had a baby and start leaking a little bit, so they start doing a lot of really fast Kegel exercises. But if you only tighten and never learn how to relax those muscles, eventually they don’t stop being tight. And then when you want to have intercourse, your partner may say it feels like a wall, or a hard donut. Also orgasms change because those muscles aren’t moving anymore. So just as floppy muscles provide less sensation, the same goes for tight muscles that don’t move.
When those muscles are tight and immovable, they don’t fully close around the urethra. So when you sneeze or cough or jump, you leak.
A tight pelvic floor is common in younger women who do a lot of yoga, Pilates or running because in those activities you’re always pulling up and in, but never relaxing. It’s also common in post-menopausal women because the lack of estrogen reduces blood flow to muscles. What happens when you have a muscle cramp? The muscle tightens and can’t get any blood flow, so there’s no energy to help un-cramp. The same thing happens with pelvic floor muscles.
Who should I talk to if I’m having pelvic floor issues?
Undoing an overly tight pelvic floor by yourself is difficult. The most common referrals I make [to customers] are to pelvic floor therapists. And the good news is most insurance plans and Medicare cover this treatment. When we [opened] the store almost 25 years ago, there was one pelvic floor therapist in Wisconsin. Now they’re everywhere, which really highlights how common the issue is.
For more information, visit A Woman’s Touch at sexualityresources.com.