Sexuality and Aging, Part 3 of 3: When Health Enters the Bedroom

A Couple Sharing an Intimate Moment Together

Medical conditions, medications, and sexual health as we age

In the first two parts of this series, we talked about how our bodies and sexual response change with age, and then about something even more complicated: desire.

But another important part of the conversation is missing.

Sometimes a change in our sex life isn't really about aging at all.

It may be about health.

Sexual function depends on an extraordinary number of systems working together. Our brain, nerves, blood vessels, hormones, muscles, emotions, medications, sleep, and overall physical health can all affect sexual function.

That means a change in sexuality can occasionally be one of the first clues that something else is happening in the body.

And yet sexual health is still something many people hesitate to bring up with their medical providers.

Maybe it's embarrassing. Maybe they assume nothing can be done. Or perhaps they think:

"I'm getting older. This is just what happens."

Sometimes it is related to aging.

But sometimes it isn't.

Sexual Health Is Health

We tend to put sexuality into its own little box.

We talk about heart health, brain health, bone health, and mental health. Sexual health somehow gets separated from the rest.

But physiologically, it isn't separate at all.

Consider what has to happen for sexual activity to occur.

The brain has to identify and react to sexual stimulation. Nerves have to transmit signals. Blood vessels have to deliver adequate blood flow. Hormones influence desire and sexual response. Muscles and joints have to allow movement without considerable pain.

And psychologically, a person has to feel safe and comfortable enough to experience intimacy.

So when something changes sexually, there can be many possible explanations.

The Heart and Blood Vessels Matter

Sexual function is closely related to cardiovascular health.

An erection, for example, depends heavily on healthy blood flow. Conditions that damage blood vessels—such as hypertension, diabetes, high cholesterol, and atherosclerosis—can also interfere with sexual function.

That is one reason new erectile dysfunction deserves attention rather than automatically being attributed to age.

In some people, erectile dysfunction can precede more obvious manifestations of cardiovascular disease.

That doesn't mean every episode of erectile difficulty indicates heart disease. Sexual performance can be affected by stress, fatigue, alcohol, medications, anxiety, and many other factors.

But persistent or new erectile dysfunction is worth discussing with a medical expert.

There is another question I sometimes hear:

"Is sex safe for my heart?"

For most people with stable cardiovascular disease who can tolerate ordinary physical activity without major symptoms, sexual activity is generally safe. But someone with unstable heart disease, significant chest pain, severe shortness of breath, or other concerning symptoms should talk with their medical professional about what is appropriate for them.

Sex shouldn't be a cardiac stress test you perform on yourself.

Diabetes Can Affect Sexual Function in Several Ways

Diabetes is a good example of why sexual health involves more than one organ system.

Over time, diabetes can affect both blood vessels and nerves.

For men, that can contribute to erectile dysfunction.

For women, diabetes may cause reduced genital sensation, changes in lubrication, and difficulty with arousal or orgasm. Diabetes can also increase the risk of certain infections that make sexual activity uncomfortable.

This is another reason managing diabetes isn't only about an A1C number.

We are trying to protect the blood vessels and nerves that affect function throughout the entire body.

Neurologic Conditions Can Change Sexuality

Sexual response begins in the brain, so neurologic disease can affect sexuality in many different ways

Stroke, Parkinson's disease, multiple sclerosis, spinal cord disorders, neuropathy, and other neurologic conditions may affect sensation, movement, arousal, erections, lubrication, or orgasm.

Neurologic disease can also affect communication, cognition, and behavior.

Dementia raises particularly complicated questions because sexuality doesn't necessarily disappear when cognition changes.

A person living with dementia may continue to want affection, touch, companionship, and sexual intimacy.

But as cognitive impairment progresses, issues of consent and capacity become increasingly important.

Can the person understand what is happening?

Can they communicate whether they want or do not want the interaction?

Do they recognize the person with whom they are being intimate?

Can they change their mind?

Those questions deserve thoughtful, individualized consideration. A diagnosis of dementia alone does not automatically erase sexuality, but cognitive impairment can change the ethical and safety considerations about sexual activity.

Pain Can Quietly Take Over a Sex Life

Arthritis, back pain, hip problems, pelvic pain, and other musculoskeletal conditions become more common with age.

Pain can make certain sexual positions uncomfortable or even impossible.

But chronic pain can affect sexuality even when someone isn't experiencing pain during sex itself.

Living with pain is exhausting.

It impacts sleep. Mood. Energy. Movement. Body image. And sometimes simply the desire to be touched.

Adaptation can make a tremendous difference—changing positions, using pillows for support, choosing times of day when pain is better controlled, or expanding the definition of sexual activity beyond intercourse.

Physical or pelvic-floor therapy can also help with some conditions.

The goal isn't necessarily to make sex look the way it did decades ago.

The goal is to find what is comfortable and meaningful now.

Cancer and Its Treatment Can Change More Than the Body

Cancer can affect sexuality in ways that are both physical and emotional.

Breast surgery can change body image and sensation.

Prostate cancer treatments can affect erections, ejaculation, and urinary function.

Pelvic surgery and radiation can affect sexual function.

Hormonal treatments for breast or prostate cancer may dramatically affect hormone levels and sexual desire.

And then there is the emotional experience of cancer itself.

Someone may be grateful to be alive while simultaneously grieving changes in their body or sexual function.

Those feelings can coexist.

Surviving an illness doesn't mean someone isn't allowed to care about sexuality afterward.

Quality of life matters, too.

Bladder and Urinary Problems Matter More Than We Realize

Urinary symptoms are common in later life and can markedly affect intimacy.

Someone worried about leaking urine during sex may avoid sexual activity entirely.

A person who gets up repeatedly during the night to urinate may be exhausted.

Prostate symptoms can disturb sleep and sexual function. Pelvic-floor disorders and vaginal changes after menopause may affect both urinary and sexual symptoms.

Sometimes treating what seems like a "bladder problem" improves much more than the bladder.

Sleep May Be Part of the Story

Sleep deserves a place in this conversation because it affects nearly everything else.

Sleep apnea, insomnia, restless legs, chronic pain, nocturia, and broken sleep can leave someone chronically fatigued.

And exhaustion is not particularly conducive to sexual desire.

As we discussed in Part 2, some couples eventually sleep in separate bedrooms because one partner snores, moves throughout the night, keeps a different schedule, or sleeps better alone.

Sleeping separately isn't necessarily a relationship problem.

But untreated sleep disorders can certainly become a health problem.

If someone has loud snoring, witnessed pauses in breathing, significant daytime sleepiness, or other symptoms suggestive of sleep apnea, that deserves evaluation for reasons that go far beyond sexual health.

Sometimes It's the Medication

This is one of the first things I consider when a patient tells me something has changed.

What medications are you taking, and has anything changed recently?

Several commonly used medications can affect sexual desire or function.

Some antidepressants can reduce libido, delay orgasm, or make it difficult to achieve orgasm.

Some blood-pressure medications can contribute to erectile difficulties.

Certain medications used for prostate symptoms or prostate cancer can affect erections, ejaculation, or desire.

Sedating medications may reduce energy and arousal.

Opioids can affect hormone levels when used chronically.

And sometimes the issue isn't a single medication—it is the cumulative effect of several medications.

That doesn't mean someone should stop a medication because it might be affecting their sex life.

Don't stop prescribed medications without discussing it with your healthcare professional.

But sexual side effects are legitimate side effects.

They belong in the medication conversation.

Sometimes another medication can be substituted. Sometimes the dose can be adjusted. Sometimes you can treat the underlying condition differently.

The first step is simply mentioning it.

Menopause Symptoms Are Treatable

In Part 1, we discussed genitourinary syndrome of menopause, or GSM.

Declining estrogen can cause vaginal and vulvar tissues to become thinner, drier, less elastic, and more easily irritated.

For some women, intercourse becomes uncomfortable or painful.

And when something repeatedly hurts, the brain learns something very quickly:

Avoid it.

Over time, pain can also affect desire.

Fortunately, there are treatment options.

Lubricants can reduce friction during sexual activity. Vaginal moisturizers may help with ongoing dryness. Some women benefit from low-dose vaginal estrogen or other prescription therapies.

Treatment should be individualized, particularly for people with complex medical histories or certain hormone-sensitive cancers.

But the important message is simple:

Painful sex isn't something you have to tolerate because you've gone through menopause.

Erectile Dysfunction Is Treatable, Too

Similarly, erectile dysfunction is common, but there are treatment options.

Treatment begins by asking why it is happening.

Is there vascular disease?

Diabetes?

A medication effect?

Low testosterone accompanied by appropriate symptoms?

Neurologic disease?

Anxiety?

Relationship stress?

Sleep apnea?

Once contributing factors have been evaluated, treatments may include medications such as PDE-5 inhibitors, devices, injections, specialist treatments, or changes to contributing medications and health conditions.

And there is an important safety point here: erectile-dysfunction medications such as sildenafil and tadalafil can interact dangerously with nitrate medications used for chest pain.

That is why treatment should fit within someone's overall medical history—not simply because a medication is available.

Don't Forget Sexually Transmitted Infections

There is one final topic that sometimes surprises people when we discuss sexuality and aging.

Sexually transmitted infections do not have an age limit.

Pregnancy may no longer be a concern, which means condoms may disappear from the conversation.

People may also enter new relationships after divorce or the death of a partner after decades of monogamy. They may not have had to think about STI prevention since they were young adults.

But older adults can and do acquire sexually transmitted infections.

New sexual relationships still warrant conversations about sexual history, protection, and appropriate testing.

Sexual health matters at 70, 80, and beyond.

So When Should You Talk to Your Healthcare Provider?

You don't need to wait until something becomes severe.

Bring it up if you notice a significant change that concerns you.

That might include new or persistent erectile dysfunction, pain during sex, vaginal or genital discomfort, bleeding, an abrupt change in sexual desire, difficulty with orgasm, new urinary symptoms associated with sexual activity, or a sexual side effect that began after starting or changing a medication.

And you don't need sophisticated medical language.

You can say:

"Something has changed in my sexual health, and I'd like to talk about it."

That is enough to start the conversation.

Sexuality Is Part of Healthy Aging

Throughout this three-part series, we've talked about changing bodies, changing desire, relationships, illness, medications, sleep, pain, and intimacy.

But there is a larger point behind it all.

Healthy aging isn't simply about accumulating more birthdays.

It is about retaining the things that contribute to quality of life.

Independence matters.

Mobility matters.

Cognition matters.

Relationships matter.

And for many people, affection, sexuality, pleasure, and intimacy matter, too.

What intimacy looks like at 80 may be very different from what it looked like at 30.

That doesn't make it less meaningful.

Sometimes aging requires us to adapt.

Sometimes health conditions require us to adapt even more.

And sometimes what we assume is an inevitable consequence of getting older turns out to be something we can actually address.

Perhaps the most important thing we can do is become comfortable enough to talk about it.

Sexuality isn't separate from health. It is part of health, and it doesn't come with an expiration date.

This blog post is for educational purposes and not intended as advice; please discuss all medical concerns with your doctor.