— Vaginal dryness, erection challenges, safe sex and more
By Ellen Uzelac
With most physicians ill prepared to talk about sexual health and many patients too embarrassed or ashamed to broach the subject, sex has become this thing we don’t discuss in the examining room.
“So many doctors talk about the benefits of nutrition, sleep, exercise — but they don’t talk about this one really essential thing we all share: our sexuality,” says Evelin Dacker, a family physician in Salem, Oregon, who is dedicated to normalizing sexual health in routine care. “We need to start having this conversation.”
Starting the conversation about sexual health
Sexual wellness experts suggest first talking about a physical problem such as a dry vagina or erectile challenges and then segueing into concerns about desire, low libido and intimacy.
As Joshua Gonzalez, a urologist and sexual medicine physician in Los Angeles, observes: “Patients sometimes need to be their own advocates. If you feel something in your sex life is not happening the way you would like it to, or if you are not able to perform sexually as you would like, never assume that this is somehow normal or inevitable.”
Often, there are physiological issues at play or medications that can alter your sexual experience. “If you’re interested in having sex,” Gonzalez says, “there are often real solutions for whatever the problem may be.”
Here are six questions to help steer the conversation in the right direction.
1. What can I do about unreliable erections?
Erectile dysfunction is common in older men — 50 percent of men in their 50s will experience erectile challenges, Gonzalez says, and 60 percent of men in their 60s, 70 percent of men in their 70s, and on up the ladder.
The good news: There are fixes. “This doesn’t mean giving up on having pleasurable sex at a certain age,” Gonzalez says. The two primary things he evaluates are hormone balance and blood flow to the penis. A treatment plan is then designed based on those results.
Some older men also find it often takes time and effort to ejaculate. Gonzalez suggests decoupling the idea of ejaculation and orgasm. What many men don’t realize: You can have an orgasm with a soft penis and without releasing any fluid at all. “Your orgasm — the pleasure component — is not going to change.”
Also good to know: Sexual health is a marker of overall health. As an example, erectile dysfunction can be a predictor of undiagnosed health issues such as heart disease and diabetes years before any other symptoms arise, says Gonzalez.
2. Sex is different now. My body is no longer young but I still have sexual urges. How do I accommodate this new normal?
Dacker often asks her older patients: How is the quality of your intimacy? Is it what you want it to be? Have you noticed a shift as you’ve gotten older and what does that mean to you?
“Naturally, as we age our bodies start working differently,” she says. “I like to reframe what it means to be sexual by expanding our intimate life, doing things that maybe you haven’t thought of doing before.”
Dacker, who teaches courses on how to be a sex-positive health care provider, suggests exploring each other in new ways: dancing, eye gazing, washing one another while bathing, giving hands-free coconut oil massages using your stomach, arms and chest. She’s also a fan of self-pleasure.
“There’s so much pleasure that doesn’t involve penetration, orgasm and erections,” she adds. “It’s not about performance, it’s about pleasure.”
3. My vagina hurts when I have penetrative sex to the point that I’m now avoiding it. What can I do?
A lack of estrogen in older women can cause the vaginal wall to get really thin, resulting in dryness, irritation and bleeding when there is friction.
“It can be uncomfortable with or without sex,” says Katharine O’Connell White, associate professor of OB/GYN at Boston University and vice chair of academics and the associate director of the Complex Family Planning Fellowship at Boston Medical Center. “What people don’t realize is that what they’re feeling is so incredibly common. A majority of postmenopausal women will experience this.”
White offers a three-part solution for vaginal dryness: If you’re sexually active — and even if you’ve never used a lubricant before — add a water-based lube during sex play. Also, consider using an estrogen-free vaginal moisturizer, sold in stores and online, to help restore the vaginal lining. Finally, think about adding back the estrogen that the body is craving through medically prescribed tablets, rings or creams that are inserted into the vagina.
White also advises patients to engage in 20 to 30 minutes of foreplay before penis-in-vagina sex. “The whole body changes and the vagina gets wet, wider and longer, which can go a long way to alleviating any discomfort,” she says.
4. Urinary incontinence is interfering with my sex life. How can I control it?
Because the bladder is seated on top of the vagina, the thinning of the vaginal wall can also impact the bladder. When you urinate, it can burn or you will want to pee more often, symptoms typical of a urinary tract infection, according to White.
Some women feel like they need to urinate during sex, which, as White says, “can pull you out of the mood.” Her advice? “Pee before sex and pee after sex.” She also suggests using vaginal estrogen to plump up the walls of the vagina and, by extension, the bladder.
5. I’m interested in dating again. What screenings for sexual wellness should I get — and require of a new partner?
Fully understanding the importance of reducing your risk for sexually transmitted infections (STIs) should be front and center as you reenter the dating scene, according to nurse practitioner Jeffrey Kwong, a professor at the School of Nursing at Rutgers University and clinical ambassador for the Centers for Disease Control and Prevention’s “Let’s Stop HIV Together” campaign.
“Individuals should be screened if they’re engaging in any sort of sexual activity — oral, vaginal, anal — because many times, some of these conditions can be asymptomatic,” he says. “You can transmit without symptoms and vice versa.”
Screening may involve a urine or blood test or swabs of the vagina, throat or rectum. With STIs soaring in older adults, Kwong suggests testing for HIV, hepatitis C, hepatitis B, chlamydia, gonorrhea and syphilis. In early 2024, the CDC reported that syphilis cases had reached their highest level since the 1950s.
6. My doctor was dismissive when I brought up sex, basically saying, At your age, what do you expect? What should I do now?
Sex is a special part of life no matter how old you are. “If you’re with a doctor who brushes aside any of your concerns, it’s time to find a new doctor,” White says.
Finding a good doctor, she adds, is no different from looking for an accomplished hair stylist or a reliable mechanic: Ask your friends.
“I’m horrified when I hear about things like this,” she adds. “Any good doctor really wants you to bring up the things that concern you.“
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