Midlife Sex: The (Very) Good, the Bad, and the Rarely Discussed

I’ve been an OB-GYN for a long time. I can count on one hand the patients over 50 who walked in and said, “Let’s talk about my sex life.” And I’ll admit that I didn’t always ask. Not because I didn’t care, but because if she said something that wasn’t good, I knew there was little I could do to help. I wasn’t alone. In a national study of more than 3,000 older adults, only 22% of women had discussed sex with a doctor since turning 50. For men, it was 38%. So let’s fix that here, starting with the numbers almost nobody quotes. I think you’ll find these interesting!

The (very) good

Most of us are still having sex! Among people aged 57 to 64, 73% were sexually active. At 65 to 74 it was 53%, and even at 75 to 85, about a quarter. As for the women who weren’t having sex, almost half of them said they were satisfied anyway. This is important because we tend to assume that people who aren’t sexually active are unhappy about this. Many aren’t. Among older women, sexual satisfaction actually rose with age.

Here’s the stat I love most: The orgasm gap isn’t biology. In a survey of more than 52,000 adults, 95% of heterosexual men said they usually or always reach orgasm during sex, compared with 65% of heterosexual women. For lesbian women, it was 86%! That gap comes largely from technique and habit, which means it can be learned at any age. Women reached orgasm more often when sex included kissing, hands, or oral sex, and when they asked for what they wanted. Medicine didn’t publish a full, accurate map of the clitoris until 2005. Can you believe that?! If you’ve never had an orgasm, or haven’t in years, you’re not broken. Most of us were simply never taught.

Desire often doesn’t come first, either. For many women in long relationships, it shows up after things get started. Researchers call this responsive desire, and it’s a normal pattern, not a disorder. Waiting to feel “in the mood” before you begin can mean waiting forever.

The bad

Pain is common. Dryness, burning, and painful sex after menopause have a name: genitourinary syndrome of menopause (GSM). It affects somewhere between 27% and 84% of postmenopausal women. In one long-term study, vaginal dryness nearly doubled, from 19% of women in their 40s and early 50s to 34% in their late 50s and 60s.

The good news inside the bad news is that the treatment with the strongest evidence just got a long-overdue reputation correction. That treatment is low-dose vaginal estrogen. In more than 45,000 women, it wasn’t linked to stroke, breast or uterine cancer, or blood clots, and in late 2025 the FDA moved to remove its boxed warning. There is minimal to no systemic absorption of vaginal estradiol, it rarely affects your partner after contact exposure, and it is safe for most women who have had breast cancer. What doesn’t work is the vaginal laser, which causes a burn of the tissue in the vagina in an effort to “revitalize” it. This did no better than a sham procedure in a randomized trial.

Also, sometimes the pain isn’t dryness at all. Lichen sclerosus (LS) is a treatable skin condition of the vulva. Two in three women who had it were first told it was something else, usually yeast, and diagnosis took about four years. If you’ve been treated for “yeast” over and over, ask for a vulvar exam and ask about LS.

The rarely discussed

Before you blame your hormones, check your medicine cabinet. Depending on the drug, 26% to 80% of people starting an antidepressant develop sexual side effects. Some alternatives don’t carry that effect, but that’s a conversation for your doctor, not a reason to stop a medication on your own.

His erections are a heart check. This is important since now erectile dysfunction is considered a potential surrogate marker for cardiovascular disease in men. ED was linked to a 45% higher risk of a later heart event, about the same as smoking. New ED is worth a doctor’s visit, before someone calls in a prescription for Viagra, for both of your sakes.

There’s no true “female Viagra,” but there is flibanserin, a daily bedtime pill for low desire. Its benefit is modest: Women taking it had about one more satisfying sexual encounter a month, and those on a placebo got more than halfway there. It also carries risks, like dizziness, sleepiness, and fainting from low blood pressure (especially with alcohol), and it costs $150 or more a month without insurance.

The supplement aisle is not your friend. Of 776 supplements the FDA caught with hidden drugs, 353 were sold for sexual enhancement, and nearly half of those contained sildenafil, the active drug in Viagra. If it works fast, be suspicious.

About half of American women have used a vibrator, and recent users scored higher on desire, arousal, and orgasm. It’s normal, common, and useful. Remember that toys can be used solo and with a partner, which can really enhance the experience for both of you. If you have never tried one, I strongly recommend it!

And if you’re dating again: From 2012 to 2022, syphilis cases among people 55 and older rose sevenfold. Rates are still low. Also, some doctors give the HPV vaccine off-label to women over 45. It’s approved only through age 45 because that’s the oldest group it was studied in, but there may still be a benefit, so ask your doctor whether that makes sense for you. Bottom line for STIs in midlife and beyond: Pregnancy risk ends at menopause, but infection risk doesn’t.

Your turn

Only 17% of people 65 to 80 had talked with a clinician about sexual health in the past two years, and most of them brought it up themselves. So be the one who asks. Try this: “Can we talk about sex? There have been some changes since menopause and I would love to discuss some options.”

After you bring it up with your doctor, talk about it with a friend (or just send them this article). Just normalize this as a topic for discussion. The silence is the one part of midlife sex no prescription can fix. Conversation can.

WHAT TO DO WHEN SEX HURTS

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