What Happens to Sex in Midlife? A Look at the “Bedroom Gap” | Maria Sophocles | TED

So the other day,

a woman walked into my office and exclaimed:

"My vagina has betrayed me!"

(Laughter)

Not what most of us hear on a Monday morning before coffee,

but welcome to my world as a gynecologist

and sexual medicine specialist.

You know, everybody thinks of menopause as hot flashes,

but for over half of menopausal women,

it’s accompanied by sexual issues.

Things like loss of libido or painful intercourse,

even total destruction of a relationship.

It’s what I call the “bedroom gap,”

the difference in sexual expectations and capabilities

of men and women in midlife.

Now the bedroom gap is a combination of the genital effects of menopause

and deeply entrenched cultural and historical gender roles.

To understand how to close the bedroom gap

and to get the sex we want,

we have to examine its root causes.

So let's start with some science.

In menopause, the ovaries make estrogen less consistently

and eventually stop making it altogether.

And this loss of estrogen has two huge effects in the vagina.

The first is on collagen.

Less estrogen means less collagen is made,

and the quality of that collagen deteriorates

from strong and stretchy to brittle.

Ouch.

(Laughter)

The second effect of the loss of estrogen in the vagina is on blood vessels.

We need blood vessels for lubrication.

When I'm examining a patient,

I can literally see if she's deficient in estrogen.

The deterioration from thick,

ridgy, dark pink, elastic, moist tissue

to thin, dry, inelastic, pale pink,

even yellowish white tissue.

We also need blood vessels for arousal.

This is where you're supposed to wake up.

(Laughter)

Now I'm excited.

(Laughter)

When we're aroused, fluid moves ...

Fluid moves from the blood vessels

through the vaginal wall to make lubrication.

Without blood vessels, you’re not going to get wet

no matter how turned on you are.

(Laughter)

So where does this leave you?

Well, you feel dried up,

you can't get wet,

your vagina seems to be on fire and --

(Laughter)

Your partner perceives your discomfort,

then you feel bad,

then your partner feels guilty,

and then you feel as if you have wrecked the whole moment.

I will never forget, a patient said to me once,

“Dr. Sophocles, when my partner and I have sex,

we sing this Johnny Cash song."

(Laughter)

Oh, you know it?

(Laughter)

"Ring of Fire."

(Laughter)

"We sing it, I sing it

because I have to sing and laugh,

or else I would cry and it would spoil the moment for him."

For him.

So while women are living in this ring of fire, mercy sex world,

on the other side of the mattress --

(Laughter)

things are a little different.

See, for 25 years,

men have had a relatively safe, reliable,

available medical option for erectile dysfunction.

What was first invented to firm up a floppy penis

has now become a global phenomenon

to optimize male sexual performance.

Now, Viagra did not cause the bedroom gap, but I believe it has widened it.

And by the way, it's not men's fault.

They are just availing themselves

of what gender-biased modern medicine has on offer.

True.

But while middle-aged men are benefiting from a rock hard,

medically enhanced erection,

their female partners are literally left hung out to dry.

(Laughter and applause)

So here's the good news, women do have options,

but they just don't seem to avail themselves of them.

Why?

What's the hold up?

Well, one problem may be

that many doctors don't feel comfortable talking to female patients

about menopause and sexual issues

because they feel they were never properly trained.

And I think this is true.

Our medical system is woefully outdated.

In fact, one study showed

that two-thirds of medical training programs in the US

have just one lecture on menopause, one.

Which may explain why doctors are uncomfortable

and why 75 percent of women

who go to doctors to seek care for menopausal problems

come away empty-handed.

This has to change.

Because every one of us is going to go through menopause

and experience the loss of estrogen.

And there are a lot of us right now.

Globally, there are 1.1 billion women right now

who’ve reached menopause and post-menopause.

And almost half of them are suffering from sexual issues

largely quietly,

and it's probably underreported.

I know because for 28 years

I have listened to your stories

on five continents,

and I can tell you that the bedroom gap

cuts across race, ethnicity,

economics, education and geography.

It is universal and ubiquitous.

It's also lasting a lot longer.

See, women are outliving men by five to six years,

and they're spending more than a third of their lives after menopause.

So there are more postmenopausal women who are single, widowed, divorced.

Some of them want to be intimate.

They go online,

they swipe left, they swipe right,

they start dating, they start having sex.

And this is great.

But between the issues inherent in the bedroom gap,

Viagra widening that gap,

and the complexities of online dating,

it's no wonder you feel your vagina has betrayed you.

But it's not your vagina's fault.

No.

What has betrayed you

is not only the biology of aging

but history

and culture.

And gender roles etched in sexual stone over millennia.

Sexual dogma that decrees

that a woman's role in the bedroom is to please,

to serve.

To not impede the sexual pleasure that a man is entitled to.

Now, we’re not going to change a millennia of sexual scripting in a TED Talk.

But I can offer you this.

Since we know that deficiency of estrogen

makes the vagina dry and unpleasant,

then maybe one solution to closing the bedroom gap

might be to replace that vaginal estrogen.

Uh-oh, I see the look on your face.

(Laughter)

I know what you're thinking.

You're thinking, "Estrogen?

What about the cancer risk?"

Well, I get it.

We have to address this collective fear of estrogen and cancer.

That fear stems from the Women's Health Initiative,

the media storm that surrounded the release

of that data 20 years ago.

That study examined the risks of oral estrogen

and cancer, among other things,

not vaginal estrogen.

So here's the key point.

Estrogen behaves differently

depending on where and how it's used.

Check it out.

Vaginal estrogen works genitally, locally and has positive effects.

Systemic estrogen can have positive or potentially negative effects

depending on the target tissue.

Vaginal estrogen has been out since 1946

and studied extensively

and has never been shown to cause breast or other cancer.

But we, the big we,

have made vaginal and systemic estrogen falsely equivalent.

We have thrown the baby out with the bathwater.

Our fear does not discriminate.

And now far too many women don't use estrogen at all.

So where does this leave us?

Well, the thing is,

we have a right to comfortable sex.

And a right to pleasurable sex.

(Applause)

Yeah.

(Cheers and applause)

So the thing is,

we talked about vaginal and systemic estrogen,

and there are even other medications we can use, vaginal and oral,

that will help us

to close our bedroom gap.

The other avenue to close the bedroom gap is advocacy.

How can you close your bedroom gap

so that you can enjoy sex?

Or better yet, how can you never have one happen in the first place?

I’m talking to you, millennials and Gen Zers.

Well, one, get educated.

Read credible sources.

Find clinicians invested in sexual health.

Two,

talk about it to each other,

to your clinicians, to your partners.

Talk without shame or blame and get specific.

What hurts?

What feels good?

Get sexually creative.

And don't do anything that doesn't feel good.

(Applause)

And number three, reframe sexual and genital health

as a lifelong maintenance project.

And don't think that just because you can't get wet

or you have wimpy orgasms

that that can't be fixed.

Because, here's the deal,

which you already heard in this talk.

We have a right to comfortable sex

and a right to pleasurable sex.

So let's move

the sexual equality needle forward.

Let's start with young people,

young men and women.

It is time

for sex ed to progress beyond getting a condom on a banana.

(Cheers and applause)

It is time for sex ed to prioritize

equal sexual pleasure for men and women.

So they learn it right from the beginning

when they're starting to have sex.

And it is time to revamp medical education

to keep up with the demographic explosion of menopausal women.

So that doctors have the tools

and the information they need to provide to women

so they don't leave empty-handed.

And it is far past time

for the concept of sexual pleasure to be gender-neutral.

Because it's never too early to start.

It's never too late to improve equal sexual pleasure for men and women.

And let's face it,

sexual health is part of long-term human health.

We know that staying sexually active reduces blood pressure,

improves cardiovascular health,

decreases stress and depression and anxiety

and is linked to longevity.

And we, women,

we must emancipate ourselves

from the rigid roles of sex for procreation

or male pleasure.

My big hope

is that in closing the bedroom gap,

we take one small sexual step

towards gender equality for all of us.

Thank you.

(Cheers and applause)