Self-Medication and the Use of Medicines Without Medical Advice

Why This Article Exists

A few years ago, a fifty-seven-year-old schoolteacher wrote to me after reading one of my articles about menopause. Her message was short and sincere. For more than two decades, she explained, she and her husband had shared a joyful and playful love life. Then her periods stopped, and everything changed. Intercourse began to sting. Her body responded slowly. She started to avoid intimacy, not because she wanted less love, but because closeness had become a source of worry. In the end she asked me a single question. Is this the end of my sex life, or is there something I can do?

The honest answer is that there is a great deal she can do. This article answers her question in three parts. It looks at the positions that work best after menopause. It maps the points of excitation that women can use and enjoy. It explains how orgasm changes, and what still makes it possible. Everything here is based on published medical research and on clinical guidance from recognized societies. At the same time, it is written in everyday language, because medical knowledge should belong to the woman who lives it.

Before we begin, one message matters more than any technique. You are not broken. Your body is not failing. Menopause is a change of season, not the end of the garden. In fact, many women discover that midlife intimacy becomes richer, slower, and more honest than anything they knew in their twenties. What changes is the map, and this article is written to help you read the new one.

What Is Really Changing Inside Your Body

The first step is to understand the body you are living in today. When the ovaries slow their production of estrogen, the whole genital system feels it. The walls of the vagina become thinner and less elastic. Natural moisture declines. Blood flow to the tissues is less generous. Even the clitoris, which many people imagine as a small and simple part, is rich in estrogen receptors and responds to the same hormonal change. None of this means you have lost your capacity for pleasure. It means the machinery works differently, and it asks for different care.

Doctors now call this collection of changes the genitourinary syndrome of menopause, or GSM. The term was introduced in 2014 by two major societies. They are the International Society for the Study of Women's Sexual Health and the North American Menopause Society. It replaced older, more frightening words such as atrophy (Portman and Gass, 2014). The symptoms include dryness, burning, irritation, a feeling of pressure, and pain during intercourse. They are common, yet rarely discussed. The American College of Obstetricians and Gynecologists reports that up to half of menopausal women are affected. The North American Menopause Society gives an even wider range. In its counting, between one quarter and more than eight in ten women are affected, depending on how strictly the signs are measured (ACOG, 2019; NAMS, 2020).

The most reliable research comes from studies that follow the same women for years. The Study of Women's Health Across the Nation, known as SWAN, followed thousands of women through the menopausal transition. It found that desire, arousal, and frequency of sexual activity declined in the years around the final period. Pain during intercourse increased at the same time (Avis and colleagues, 2009). A later SWAN analysis showed that the decline in sexual function began about twenty months before the last period. It then slowed after roughly one year of menopause (Avis and colleagues, 2017). In other words, the hardest stretch is the transition itself, and many women stabilize after it.

It is important to be precise about the cause. In a classic study of middle-aged women, researchers asked whether changes in sexual function were due to aging or to menopause itself. They concluded that the menopausal transition explained most of the change, though age still played a smaller role (Dennerstein and colleagues, 2001). This is a hopeful finding. It means these changes are hormonal and treatable, not a verdict about your body.

One more finding deserves attention, because it changes the emotional picture. In a large American population study, more than four in ten women reported at least one sexual problem. Fewer than one in four reported distress about it. What is more, distress about sexuality was least common among the oldest women in the study (Shifren and colleagues, 2008). Put simply, problems are common, but suffering is not inevitable. Many women learn to adapt, and you can learn it too.

The Mind Comes First

The most powerful sexual organ in your body sits between your ears. When the mind is racing, the body cannot follow. Menopause often arrives together with a crowd of busy thoughts. The children leave home. Aging parents need care. Work pressures grow. A woman looks in the mirror and sees a body that no longer matches the image of her younger self. Add to this the memory of recent pain, and the brain builds a wall before the bedroom door is even opened.

Science supports a practical answer to this problem: attention training. In a randomized trial with women diagnosed with sexual interest and arousal disorder, group mindfulness-based therapy improved desire and arousal. It also reduced sexual distress more effectively than supportive sex education alone. The benefits lasted up to twelve months (Brotto and colleagues, 2021). A newer pilot study found that a virtual mindfulness group lowered sexual distress in middle-aged and older women as well (Thomas and colleagues, 2023). These were not relaxing spa treatments. They were structured sessions in which women learned to observe their thoughts without judging them. They also learned to return their attention, again and again, to their own body.

You can begin this practice at home tomorrow. Find ten quiet minutes, three times a week. Sit comfortably, close your eyes, and take five slow breaths. Then move your attention slowly from your forehead to your jaw, your shoulders, your belly, and your pelvis. Notice each sensation without trying to change it. When a thought arrives, greet it like a guest, and gently come back to the breath. That is the whole practice. Its purpose is not spiritual. Its purpose is to teach your nervous system that your body is safe, and that you can stay present when pleasure begins.

Along the same lines, therapists have long promoted the idea of good enough sex. Two experienced clinicians, Metz and McCarthy, argue that couples should stop judging intimacy as a performance. They suggest treating it as a shared experience that is sometimes wonderful, sometimes ordinary, and always acceptable (Metz and McCarthy, 2010). A failed attempt at orgasm is not a failed evening. A warm embrace with laughter is a success. This small change of definition releases enormous pressure.

Finally, you must speak. Words are the cheapest lubricant ever invented. Choose a quiet moment, not the bedroom. Say something like this: I love you, and I want us to stay close. My body has changed, and I need your help to rediscover it. Can we try things slowly, and tell each other what feels good? Use sentences that begin with I rather than you. A woman I will call Nadia, fifty-two, told her partner exactly this on a Sunday morning. He was relieved, because he had believed he was failing her. Within a month they had rebuilt a routine of gentle touch that neither of them had dared to ask for.

One more thought about desire. Many women in midlife discover that their desire no longer appears first, like hunger before a meal. Instead, it wakes up after pleasure begins, like a small fire catching wood (Basson's model of responsive desire, described in ACOG, 2019). If this is true for you, the practical consequence is simple. Do not wait to feel like it before you start. Start with five minutes of warm touch, and let the feeling arrive on its own.

Prepare the Ground: Small Daily Habits That Work

Before any position or technique, there is preparation. This is the layer of practical advice that makes the biggest difference, and it begins long before the bedroom.

The first habit is hydration from outside. Vaginal moisturizers are used on a regular schedule, two to three times a week, independently of sex. They nourish the tissues over time. The North American Menopause Society gives this recommendation the strongest level of evidence (NAMS, 2020). Lubricants are different. They are applied at the moment of intimacy, and they reduce friction, which is the true enemy of comfort after menopause. Choose a water-based or silicone product, and keep it within arm's reach. Use more than you think you need, and reapply without embarrassment. If you use condoms, avoid oil-based products, which can damage them.

The second habit is a longer warm-up. A body that was lubricated in seconds at twenty-five may need fifteen or twenty minutes of affectionate touch at fifty-five. This is not a defect. It is the new normal, and it can be delicious. A warm bath, a back massage, kissing, and gentle caressing all tell the tissues to prepare. I often advise couples to think of making love like a small ceremony with an overture, not a sprinter's start.

The third habit is the one most often neglected, and it is completely free. The pelvic floor muscles wrap around the vagina like a hammock, and they deserve daily exercise. A large systematic review and meta-analysis of randomized trials looked at pelvic floor training in postmenopausal women. It found meaningful gains in arousal, orgasm, satisfaction, and pain relief (Ferreira and colleagues, 2015; Garcia-Laria and colleagues, 2025). The exercise is simple. Squeeze the muscles you use to stop the flow of urine, hold for three seconds, release for three seconds, and repeat eight to twelve times. Do three sets a day. Breathe normally, and do not squeeze your stomach or your legs. Ruth, fifty-eight, started this routine while waiting for her tea to brew. After two months, she reported that her awareness of her own body had returned. Orgasms, she said, had become easier to reach.

When preparation is not enough, medical options are effective and safe for most women. For moderate to severe symptoms, the first-line prescription treatment is low-dose vaginal estrogen. It is applied locally and works on the tissues themselves (ACOG, 2019). Other approved choices include a vaginal insert of dehydroepiandrosterone, also called DHEA or prasterone. A third option is an oral medicine called ospemifene. All three carry the strongest level of evidence in the 2020 position statement of the North American Menopause Society (NAMS, 2020). Ask your gynecologist which option fits your health history. In contrast, be cautious about energy-based devices such as vaginal laser and radiofrequency. The North American Menopause Society notes that there are not enough well-designed placebo-controlled trials to recommend them (NAMS, 2020).

The Map of Pleasure: Where Your Body Likes to Be Touched

Every woman's map of pleasure is unique, but it is drawn on a shared landscape. Knowing the landscape turns random touch into intelligent, generous touch.

The center of the map is the clitoris, and it is far larger than the small button you see. Detailed anatomical work has shown that the visible glans is only the tip of a larger structure. Its legs and bulbs extend deep into the pelvis, hugging the vaginal walls on both sides (O'Connell and colleagues, 2005). This explains a fact that surprises many women. Deep touch inside the vagina can stimulate a network of the same erectile tissue. Researchers now speak of a clitourethrovaginal complex rather than a single spot (Jannini and colleagues, 2014). In plain words, the clitoris is not a doorbell. It is a room with many sounds.

This brings us to the famous G spot. A careful review of the evidence reached a clear conclusion. Objective studies have not proven the existence of a distinct anatomical structure that could be called the G spot (Kilchevsky and colleagues, 2012). Nevertheless, many women describe a highly sensitive area on the front wall of the vagina. In practice, this means two things. First, do not chase a myth. Second, do follow your own sensations. Many women deeply enjoy firm, rhythmic pressure on the front wall, about two to four centimeters inside, where the tissue is soft and slightly uneven. If you want to discover it, lie on your back with knees bent. Explore gently with a curved finger, using a come-here motion. Keep your other hand resting on the clitoris. Some women love this. Some prefer other zones. Both are normal.

The rest of the map deserves generous attention. The neck, the ears, the inner thighs, the lower back, the buttocks, and the perineum all carry a rich nerve supply. The area around the anus is sensitive for many women too, though it is not for everyone. Breasts and nipples are powerful arousal zones for many women. Here again, ask. The labia are exquisitely sensitive, and the hood of the clitoris responds beautifully to light gliding strokes. Notice that this map is the whole body. Women who limit touch to the genital area are often surprised to find how much more there is.

How you touch matters as much as where. In a nationally representative American study, more than a thousand women aged eighteen to ninety-four took part. Participants described remarkably diverse preferences for location, pressure, shape, and pattern of touch. About four in ten preferred one specific style above all others (Herbenick and colleagues, 2017). The direct lesson for couples is this. Never assume that what worked at thirty works at fifty-five. Ask, and ask again. Try light tracing, slow circles, firm steady pressure, and gentle rhythmic taps. Watch what the body says, and repeat what it likes. Marianne, forty-nine, told me that her lifelong favorite touch suddenly felt irritating. She was ready to conclude that her sexuality had died. In truth, her sensitivity had shifted, and a lighter, slower style brought her back to pleasure within weeks. She simply had to explain this to a partner who was eager to learn.

Positions That Make Sense After Fifty

Positions are not gymnastics. They are solutions to three small problems. The first is comfort, because a knee that aches or a shoulder that complains will destroy desire faster than any technique. The second is control, because your body knows how deep, how fast, and at what angle it can receive. The third is access to the clitoris, because most women need it to reach orgasm. Hold these three goals in mind, and every position below becomes self-explanatory.

The first position is called side by side, or spooning. Both partners lie on their sides, the woman in front, and the man enters from behind. This position has many gifts. It is gentle and unhurried. It allows the partner to reach around and caress the clitoris with a free hand, which is exactly what most women need. It puts no weight on joints, so it is ideal for women with back, hip, or knee problems. It is equally kind to men with the same difficulties. It also allows the couple to stop at any moment without an awkward change of scenery. I recommend starting here, before any other position, with a long period of outer touch before entry.

The second position places the woman on top. Its greatest virtue is control. She decides the depth, the angle, and the rhythm, and she can stop the instant something feels wrong. Leaning forward brings the bodies close and deepens penetration. Leaning backward angles the pelvis so that the front wall receives more contact. Many women find this intensely pleasurable. Gentle grinding and rocking, rather than up and down bouncing, keep contact with the clitoris. They are also easier on the knees. A pillow under each of her knees is a small investment with a large return.

The third position is a refined version of the classic face-to-face position. It deserves special mention because it was designed by a therapist to solve exactly the problem we are discussing. In the technique known as the coital alignment technique, the woman lies on her back. Her partner shifts his body upward along her torso, so that the base of his pelvis rests against her clitoris. Penetration remains shallow, and the couple moves together in a slow rocking rhythm, pressed against one another, rather than apart from one another. In the original small study, women who learned this technique reported far higher rates of orgasm during intercourse (Eichel and colleagues, 1988). The study was small and dated, but the principle has survived because it is sound. When the clitoris stays in continuous contact, orgasm becomes reachable during penetration. Try it with a pillow under her hips and a slow, patient rhythm.

The fourth position supports a woman whose vagina feels short or whose entry is uncomfortable. She lies on her back with her hips raised on a firm pillow. Her knees are bent, and her feet rest on the bed. The partner kneels between her legs and enters at a shallow angle. This position allows gentle, controlled thrusting that targets the front wall. At the same time, the raised pelvis protects the deeper tissues. Many women with genitourinary syndrome of menopause find this position the most pleasant of all, because it never demands depth.

The fifth position is entry from behind, with the woman resting her chest on pillows and her hips lifted. It offers deep, full sensation and easy access for a partner's hands. Because of this depth, it can press against the cervix. Some women find this uncomfortable, particularly if they have endometriosis or a history of pelvic pain. If it hurts, change it. There is also a gentler option. The woman stands at the side of the bed and leans her chest forward over the edge. Her partner stands behind her. Many couples prefer this version, because it takes no strain from the knees.

The sixth position is seated, with the woman on her partner's lap at the edge of a chair or bed, facing him. It is intimate, face to face, with kissing and breast contact possible. It demands little physical strength from either partner. In addition, it is excellent for men with back problems, who can lean back and let her move. It is also one of the most affectionate positions, and affection, after all, is the real motor of midlife sexuality.

Finally, remember that penetration is optional. Oral sex, manual caressing, and shared use of a vibrator are complete forms of lovemaking, not substitutes. A nationally representative study found that vibrator use among women was common. It was linked to health-promoting behaviors and positive sexual function. It was rarely associated with any harm (Herbenick and colleagues, 2009). Using a small vibrator during intercourse is not an admission of failure. It is intelligent cooperation with your own body. Celine and Marco, both sixty-one, keep a small vibrator in the bedside drawer like a first-aid kit for desire. They call it their silly little helper, and it has saved many evenings.

Orgasm After the Change: What Feels Different, What Still Works

Orgasm does not disappear at menopause, but it often changes its character. Many women describe a longer build-up, a softer or shorter peak, fewer contractions, and a slower return. Some women reach a plateau but cannot finish. Others, to their own surprise, discover deeper and more satisfying climaxes once they slow down. All of these are normal. The changes reflect lower blood flow, thinner tissues, and quieter nerve signaling. They do not reflect a loss of desire or love.

Research is clear about the most practical fact. For the large majority of women, clitoral stimulation remains the engine of orgasm. In the national study of more than a thousand women, nearly three quarters reported that clitoral stimulation was necessary for their orgasm during intercourse. For others, it at least made the orgasm feel better. Only a small minority could climax from penetration alone (Herbenick and colleagues, 2017). This single number should change how many couples make love. Most positions, especially the ones described above, are designed to bring the clitoris into the game. If a position leaves the clitoris out, the orgasm may never come. The woman will unfairly blame herself.

The pelvic floor muscles are the second engine. The recent meta-analysis of pelvic floor training in postmenopausal women found significant improvements in the orgasm domain of the validated Female Sexual Function Index (Garcia-Laria and colleagues, 2025). This makes biological sense. These muscles contract rhythmically during orgasm, and a trained, well-supplied muscle simply performs better. The daily exercise described earlier is therefore not only comfort care. It is orgasm training.

There is also a skill to relearn, and it is best practiced alone first. Self-pleasure is not a sign of failure in a relationship. It is how a woman updates her own map, at her own speed, without pressure. Set aside ten minutes, once or twice a week, with no goal and no clock. Use your fingers or a vibrator. Breathe slowly, and contract the pelvic floor gently on each long exhalation. Notice where the sensations gather, and stay with them a little longer than feels comfortable. If orgasm arrives, enjoy it. If it does not, you have still learned something valuable. Many women describe this as learning to surf a wave instead of climbing a ladder.

One more finding is liberating. In the national study, most women reported that not all orgasms feel the same. Some are clearly better than others (Herbenick and colleagues, 2017). This kills the myth of the single perfect orgasm. A quick, small climax can be lovely on a Tuesday. A long, deep one is another country. The quality depends on mood, rest, trust, position, and time. It does not depend on your competence. Therefore, judge nothing by a single evening.

As for the old dream of simultaneous orgasm, let it go gently. It is rare, it requires exhausting timing, and it is not the goal of intimacy. Masters and Johnson, the founders of modern sexual medicine, taught this half a century ago. They showed that a woman can reach complete satisfaction in the absence of orgasm, and that this is not a failure (Masters and Johnson, 1970). An orgasm lasts a moment. Intimacy lasts a decade. Keep your eyes on the decade.

When It Still Hurts, or When It Still Does Not Work

Sometimes the body refuses, despite kindness and preparation. This section is for the women who have tried, and who still suffer. Suffering is a medical matter, and it deserves a medical answer.

Pain during intercourse after menopause most often comes from the genitourinary syndrome of menopause described earlier. It can also come from an overly tight pelvic floor. Other causes include vulvodynia, endometriosis, and the consequences of surgery or radiotherapy. In every case, the first advice is the same. Do not push through pain, because pushing trains the body to defend itself. See a gynecologist who takes this complaint seriously. Consider a referral to a pelvic floor physiotherapist. These specialists treat the muscles that do not know how to relax. They sometimes use gentle internal work, or vaginal dilators that stretch the tissues gradually over weeks. Fatima, fifty-five, had endured four years of pain without telling anyone. Her pelvic floor therapy started with breathing and ended with the rediscovery of her own body. She told me that the tears she shed in the first sessions were not of pain, but of relief at being finally understood.

For GSM-related pain, the medical ladder is well established. Over-the-counter lubrication and moisturizing come first. If they are not enough, low-dose vaginal estrogen is the preferred hormonal treatment. It is applied directly to the tissues, and prescribing it is a first-line recommendation of the American College of Obstetricians and Gynecologists (ACOG, 2019). Vaginal DHEA and oral ospemifene are strong alternatives. Each is supported by the strongest level of evidence from the North American Menopause Society (NAMS, 2020). These treatments do not act on pleasure directly. They rebuild the tissue, restore moisture and elasticity, and allow sensation and entry to return. Many women describe the result as getting their body back.

Low desire is a separate issue and also treatable. The mindfulness-based group approaches described earlier have the strongest recent evidence. Their benefits lasted a full year (Brotto and colleagues, 2021). Sex therapy with a qualified professional helps couples untangle years of silent resentment. For women with distressing loss of desire, testosterone therapy can be considered on an individual basis. It is prescribed off-label in most countries. An international consensus statement recommends it only for carefully selected women, under specialist supervision, with blood levels monitored (Davis and colleagues, 2019). It is not a cosmetic product, and it is not for everyone. Let a specialist decide, after a full review.

Also review your medicine cabinet. Many common medicines can dampen arousal, delay orgasm, or reduce sensation. Several antidepressants and blood pressure treatments are known for this effect. If you take such a medicine and notice these changes, speak with the prescriber. There are usually options. Never stop a prescribed medicine on your own. Always have the conversation.

Finally, know when to ask for help. Ask for help if sex hurts, or if you have begun to avoid it. Ask if you feel sadness or guilt about your intimate life. Ask if the distance between you and your partner is growing. These are not reasons to be ashamed. They are reasons to be wise. A good doctor, a pelvic floor physiotherapist, a sex therapist, or a couples counselor can each contribute a piece of the solution. You would not hesitate to see a specialist for a knee that hurt for a year. Your intimate life deserves the same dignity.

Staying Close for the Long Run

Technique matters, but relationship is the container. Over the years, I have noticed that the couples who stay close through menopause have a few quiet habits in common. They touch each other every day without any intention of sex. A kiss in the kitchen, a hand on the shoulder, a long hug at the door. They laugh together about their awkward moments, because humor defuses shame better than any therapy. They remain curious about each other, asking new questions instead of replaying old answers. And they have a short weekly check-in, ten minutes, in which each partner says what felt good and what they need next. It sounds modest. It is revolutionary.

They also accept that rhythms differ. One partner may want lovemaking three times a week, the other once a month, and neither is wrong. The answer is not a contest but a negotiation, with generosity on both sides. In the same way, they stop keeping score. Who started it, who finished, who asked first, none of it matters. What matters is that both people leave the bed feeling welcomed.

One of my correspondents, now seventy-one, wrote to me last spring. She and her husband had recently begun using a vibrator, after fifty years of marriage. She described the discovery with delight. She said she wished she had not spent a decade feeling broken. Her words stayed with me. It is never too late to learn your body, and your partner is never too old to become a better student of it.

A Few Honest Words From the Author

After more than ten years of writing about women's health, three regrets return again and again in the letters of readers. The first is waiting too long to talk. The second is believing the myth that desire should be spontaneous and effortless. The third is enduring pain in silence, sometimes for years, out of politeness or shame. None of these regrets is deserved. Nobody taught us this part of the story. Our mothers did not have these words, and our doctors were often too hurried to ask.

Therefore, my hope for you is simple. Speak early. Prepare generously. Touch without expectation. Let pleasure lead your desire, instead of waiting for desire to lead. And when something hurts, or does not work, take it to a professional without embarrassment. Menopause is a season of change, but it is not a season of loss. It can even be a season of discovery, in which you stop performing and start feeling. You have lived long enough, and loved long enough, to deserve the whole of it.

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