We might not talk about it. In fact, the mere thought of it can cause many to blush. And sex can mean different things to different people.
‘But whatever it means to you, you cannot underestimate the importance of a good sex life’, says Dr Janine David, a GP in Porthcawl, Wales, who specialises in sexual health.
It not only helps to strengthen relationships and improve your mood, ‘but regular sex can have fundamental benefits such as improving cardiovascular health and potentially reducing the risk of prostate cancer, for instance’, she says.
But what if you’re not able to enjoy a healthy sex life? One factor you can’t change is getting older and the physical changes this wreaks.
‘But getting older in itself doesn’t prevent sex, you just need to learn how to adapt,’ says Andreas Vossler, a professor of psychology and psychotherapy at the Open University, who’s carried out research into sex and older people.
Indeed, without the life stresses and strains of younger people – looking after children and financial issues ‘which can dampen your desire to have sex’ – ‘research shows that some people in later life admit to having the best sex of their lives’, he adds.
But whatever your age, what can you do if you find your sex life is starting to dwindle, or you experience problems such as erectile dysfunction or embarrassing infections?
In this, the latest in our unique series of essential health guides, we’ve teamed up with leading experts to give you the answers…
Our sex drive is directly linked to hormones, particularly testosterone – men have around 40 times more than women
YOU’VE JUST LOST INTEREST…
Libido – or desire for sex – can vary hugely from one person to another. It can also increase or decrease over time, says Dr David.
Our sex drive is directly linked to hormones, particularly testosterone – men have around 40 times more than women, which is why they’re thought generally to have a stronger sex drive.
‘The drive derives from the hypothalamus in the brain – this area is over double the size in men compared with women, meaning men do, quite literally, have sex on the brain,’ says Dr David.
When you feel desire, signals originating in this area interact with other parts of the brain and nerves. This in turn speeds up your heart rate and increases blood flow to the genitals.
‘Many things can dampen sex drive,’ says Dr David. ‘In men, physical issues – such as putting on weight, type 2 diabetes, high blood pressure and high cholesterol – are a common cause.
‘All of these contribute to a decrease in testosterone, therefore lowering libido.’
Testosterone can also be lowered by certain medications, such as antidepressants, some high blood pressure drugs and chemotherapy or radiotherapy.
And then there’s simply getting older. ‘From around the age of 40, testosterone levels drop by 1–2 per cent a year,’ says Dr Doug Savage, a physician who specialises in sexual medicine at Leger Clinic in Doncaster.
‘By 70, men’s production is 30 per cent below the peak, which can cause decreased libido or erectile dysfunction. Obesity and diabetes can reduce it, too.’ The causes of low libido in women differ, says Jo Coker, a counselling psychologist from the College of Sexual and Relationship Therapists.
‘It’s often due to the stresses of everyday life, such as lack of sleep [particularly with young families] and relationship issues.’
The drop in hormones with the menopause can also lower sex drive and lead to vaginal dryness and discomfort, adds Dr David.
So what can help?
‘Given the huge effect stress can have on libido, psychosexual therapy can help by talking through any problems and is frequently used in conjunction with other treatments for both men and women,’ says Jo Coker. (To find a registered therapist, go to cosrt.org.uk).
More controversially for women, some experts recommend testosterone replacement therapy. Under NICE (The National
Institute for Health and Care Excellence) guidelines, women with low libido should first have a trial of conventional HRT.
As Dr Savage explains: ‘The numbers it benefits are low, and there can be side-effects, albeit rare, such as acne. For that reason, it should be considered only after other causes – such as psychological or medication-related – have been excluded.’
Another hurdle is that there are no testosterone products licensed for women, so it has to be prescribed off-licence.
For men, testosterone gels, injections (e.g. enanthate and cypionate) or daily capsules can be prescribed.
The herbal supplement ashwagandha, an evergreen shrub that grows in Asia and Africa, may help. In a 2019 study in Australia with older overweight men, the supplement was associated with a 14.7 per cent increase in testosterone over an eight-week period.
‘How it works is unclear, although it could help decrease cortisol [a stress hormone]; when levels are high it can block testosterone production,’ says Dr David.
Viagra can also be prescribed off-label for women to help with low libido. There is a ‘female’ Viagra, known as Addyi – unlike Viagra, which boosts blood flow, this changes the way the brain responds to feelgood chemicals such as serotonin. However, Addyi is not licensed in the UK.
Then there’s ‘The Golden Pill’, popularised by celebrities such as Abbey Clancy, a ‘hormone balancing supplement’, with Siberian ginseng and maca, said to improve sexual wellbeing. But the evidence for these is limited.
‘It’s important to remember that low sex drive isn’t a problem if you and your partner are happy,’ says Dr David. ‘You can still have a wonderful relationship with a low libido and what sexual encounters you do have can be fulfilling.’
Could Viagra help – or even a more radical solution?
Viagra, which increases blood flow to the penis, is available over the counter
Around 40 per cent of men in their 40s will have some degree of erectile dysfunction (ED) – difficulty getting or maintaining an erection.
This rate increases by about 10 per cent per decade: a man in his 50s has about a 50 per cent chance of having ED, and a man in his 60s has about a 60 per cent chance, according to the Massachusetts Male Aging Study.
‘Causes may be down to blood flow issues, which are more common as we age,’ says Marc Lucky, a consultant urologist and andrology surgeon.
‘They may also be a result of nerve damage due to prostate cancer treatment, for instance.’
Lifestyle can play a role, too. Sometimes simply reducing cholesterol levels and stopping smoking can help by improving circulation. Similarly, aerobic exercise (e.g. 45 minutes, three times a week, of jogging, swimming or brisk walking) can improve many cases.
Viagra, which increases blood flow to the penis, is available over the counter. But Dr Doug Savage, a GP who now specialises in sexual medicine, says prescription-only Cialis ‘may be better’.
‘Viagra lasts in the system for six hours; Cialis, 36 hours. That’s not a 36-hour erection – the drug only works in the presence of a chemical released by the body during sexual arousal. There’s also a lower-strength, daily Cialis for spontaneity.’
If there is nerve damage, prescription-only injections such as alprostadil (Invicorp) can be self-administered into the penis.
‘Patients say it’s painless and it can give you an erection within ten minutes,’ says Dr Savage.
When medication doesn’t work, penile pumps are an option. The pump action draws blood into the area, which you trap by slipping a ring over the base of the penis.
Penile implants are a last resort and ‘not an option to be taken lightly,’ says Mr Lucky. ‘Available on the NHS, these may be suitable for patients with whom all therapies have failed.’
Meanwhile, between 5 and 10 per cent of men are affected by premature ejaculation, ejaculating within two to three minutes. Psychological factors are a common cause.
‘Psychosexual counselling is an important tool, as is the medication dapoxetine [brand name Priligy, a type of selective serotonin reuptake inhibitor – drugs widely used for depression],’ says Mr Lucky.
Available on prescription, this is taken an hour or so before sex and causes a delayed reaction in the areas of the brain that trigger ejaculation. ‘It can make you last up to three times longer,’ adds Mr Lucky.
Another option is ‘delay’ sprays or creams, which contain local anaesthetics that numb the tip of the penis – you can buy these over the counter.
The start and stop technique can also help: the penis is stimulated to just before the point of orgasm, then stimulation is stopped for 30 seconds. This is repeated a few times before allowing the orgasm to follow through. It works by allowing the excitement to plateau.
The sex saboteurs
Fatty foods can impair blood flow to sexual organs and affect libido
While stress and relationship problems can affect your sex life (and alcohol can impede sexual performance), other daily activities could be sabotaging it, too:
FATTY FOODS: ‘Diets high in saturated fats contribute to the development of cardiovascular disease which can impair blood flow to sexual organs and affect libido,’ says dietitian Emer Delaney.
LOW VITAMIN D: Low levels (less than 12ng/ml) have been linked to reduced desire and orgasms in young women, according to a 2024 study in the European Journal of Obstetrics & Gynaecology and Reproductive Biology.
And a 2017 trial in the journal The Aging Male found giving men supplements improved their testosterone levels and erectile function. Vitamin D is involved in the production of testosterone and oestrogen, explains Emer Delaney.
DECAF COFFEE: Switching your daily cup of coffee to decaf could knock your sex drive. A 2015 review in the journal PLOS One found that a higher caffeine intake (two to three daily cups) was associated with a reduced risk of erectile dysfunction.
‘It’s thought to improve circulation by dilating blood vessels, which supports physical arousal,’ says Dr Roy Jogiya, a consultant cardiologist at Kingston and Richmond NHS Foundation Trust.
Making love can protect your heart – and ward off wrinkles!
An active sex life can help with many different aspects of your health…
CUTS PROSTATE CANCER RISK
Studies have shown that men who ejaculate at least 21 times a month have a lower risk of prostate cancer.
Dclining levels of oestrogen can lead to thinner vaginal tissue
Up to 50 per cent of women say menopause symptoms affect their sex life. This can include low libido and painful sex – declining levels of oestrogen can lead to reduced lubrication and thinner vaginal tissue.
‘This can cause symptoms such as itching, burning, pain with intercourse and recurrent urinary tract infections,’ says Dr Paula Briggs, former chair of the British Menopause Society.
‘Oestrogen delivered to the vagina can help,’ she says. ‘Creams or pessaries are available on prescription and over the counter. A flexible ring such as Estring releases a steady dose of oestrogen for 90 days before it needs replacing.’
‘HRT often helps, but it isn’t suitable for everyone,’ adds GP Dr Angela Wright. Vaginal moisturisers are also helpful, such as the Yes range (from chemists and on prescription), she adds.
Avoid everyday soaps as these can disrupt the natural oily skin layer that protects the vagina.
‘Wash externally with a plain emollient such as Epaderm, or something natural like coconut oil,’ says Dr Wright. ‘After washing, massage these into the vulval skin to improve blood flow. I tell my patients to “treat your vulva like a cashmere jumper”.’
Research in the journal European Urology in 2016 found that it reduced the risk by about 20 per cent.
The researchers suggested frequent ejaculation ‘may help clear potential cancer-causing substances [such as tobacco and pesticides] from the prostate’.
EASES PAIN
In a 2013 study, published in the journal of the International Headache Society, researchers found that 70 per cent of people who were sexually active during an attack reported moderate to complete relief from the migraine.
During migraine attacks people may have lower levels of brain chemicals such as dopamine and serotonin; these are both released during sex.
IMPROVES SLEEP
Three quarters of people reported they had a better sleep after sex and orgasm close to bedtime, according to a multi-centre study presented at the 2023 Sleep conference in the US. Sex induces the release of oxytocin, dopamine, prolactin and progesterone – hormones that can reduce stress.
PROTECTS HEART
Having sex at least 52 times a year is associated with a 10 per cent drop in the risk of dying from cardiovascular disease, reported the European Journal of Preventative Cardiology in 2020.
This may be because it leads to the release of hormones such as endorphins and oxytocin, reducing stress and promoting relaxation – which may lower blood pressure too, says Dr Roy Jogiya, chief medical adviser at Heart Research UK.
DELAYS MENOPAUSE
Women of any age who engaged in sex every week had a 28 per cent lower likelihood of entering menopause early, compared with those who were active less than once a month, a 2020 University College London study found. It’s thought the body may view sex as a possibility of getting pregnant so continues to ovulate, somehow delaying the menopause.
WARDS OFF DEMENTIA
Regular sex could help protect against cognitive decline, according to a 2023 study in the Journal of Sex Research, which showed that 75-90 year olds who had sex at least once a week had better cognitive function than those less sexually active.
The researchers said: ‘Sex is physical exercise which is linked to better cognitive performance by increasing blood flow in the brain.’
The rush of ‘feelgood’ hormone dopamine on orgasm also shields nerves linked to memory.
KEEPS YOU YOUNG
Men and women with an active love life look between five to seven years younger than their physical age, according to research at the Royal Edinburgh Hospital. The 40 to 50-year-olds in the study, who looked young for their age, reported having sex around three times a week rather than the average of twice a week.
The researchers put this down to endorphins released during lovemaking, which ease anxiety that can cause inflammation and damage DNA in cells, accelerating ageing.
Sex also releases growth hormone, which can make the skin more elastic and less prone to signs of ageing.
Try a ‘sleep divorce’
‘Sleep divorce’ – where couples sleep in separate bedrooms – is on the rise, with nearly one in six couples going to bed separately, according to a 2020 survey. But is it bad for your sex life?
Researchers at the University of Pittsburgh in 2012 found sharing a bed lowers the stress hormone cortisol, which may encourage feelings of security.
‘Sharing a bed can also increase the feelgood hormone oxytocin,’ says Dr Janine David, a GP who specialises in sexual health. ‘Oxytocin is released making love, but going to sleep hugging, or touching can also produce it.’
But psychologist Jo Coker adds: ‘If you share a bed and regularly get a rotten night’s sleep, that’s not good for a relationship either.’
Does mine look normal?
‘Penises come in all shapes and sizes – what you have to be aware of is what’s not normal for you,’ says andrology surgeon Marc Lucky.
Sexually transmitted infections (STIs) can trigger changes to the penis (see overleaf). Skin conditions can affect the penis, too. For instance, psoriasis causes dry, scaly patches. ‘However, if you have sores that don’t heal it’s important to get urgent medical advice,’ says Mr Lucky.
Irritated, red skin, tightness in the foreskin, swelling and unusual discharge, could be balanitis, a common condition caused by an infection. Treatment includes antifungals and antibiotics, as well as washing the penis daily using an emollient. In some cases, circumcision will be needed.
One condition can dramatically affect the shape of the penis: Peyronie’s disease, where scar tissue causes it to bend and lose length or girth when erect.
It tends to occur after an injury which leads to an abnormal wound healing process. Calcium deposits form in the tissue, causing hard plaques that tether together during an erection.
Treatment can include using a pump to pull apart the scar tissue or, ultimately, surgery.
For women, the labia can lose fat and shrink after the menopause. In some women, it even disappears. This can cause a loss of sensation. ‘Continuing to get aroused can maintain blood flow to the area, helping to keep it healthy,’ says menopause expert Dr Angela Wright.
Post menopause you might develop milia – small, white bumps on the vagina. Usually harmless, these do not need treatment. But they can be drained if bothersome.
‘Post-childbirth prolapse –where organs collapse into the vagina – can affect a woman’s sex life: symptoms can usually be improved with pelvic floor exercises, but serious cases may require surgery,’ says Dr Wright.
Another concern women have is around bodily fluids. ‘Discharge helps to clean and lubricate the vagina, and fight off infection,’ says Dr Paula Briggs, a consultant in sexual and reproductive health.
Normal discharge is off-white with a slight odour. Pregnancy, ovulation and birth control pills can lead to more discharge. But some changes are a sign to seek help, including bad odour and altered colour (dark yellow, green or grey point to infection).
If it’s brown or red and not your period, it could point to irregular menstruation, pregnancy and, very rarely, vaginal cancer.
For men, any discharge, aside from clear fluid when sexually excited, is abnormal and can point to an infection, says Mr Lucky. See your doctor.
Is it true that…
The greater the difference between a man’s index and his ring finger, the bigger his penis is likely to be, says one study
SEX IS A GOOD WORK OUT? Yes, and no. For example, in a 2013 study at the University of Quebec, in Canada, researchers measured the effects of 21 couples doing a treadmill workout, compared with having sex, both rated as moderately intense exercise: the sex took on average 24.7 minutes, with women using 69 calories on average and men, 101.
The same amount of time on the treadmill used up three times as much.
‘Sex is a form of cardiac exercise as it raises your heart rate and reduces stress levels, but it’s not the basis for the exercise an individual needs in order to keep their heart healthy,’ says Emily McGrath, a senior cardiac nurse at the British Heart Foundation.
‘It’s important people focus on getting at least 150 minutes’ moderate- intensity exercise a week.’
With 5.4 minutes the average time people have sex, that would be quite a lot of sex.
MEN’S SHOE SIZE REVEALS ALL?: It’s a popular belief, but a 2002 study at St Mary’s Hospital London found there’s no basis to this. It showed the average length when the penis was gently manually extended was 13cm, compared with the average UK shoe size (9) being around 27.5cm.
However, a man’s index finger might be more telling – the greater the difference between this and his ring finger, the bigger his penis is likely to be, reported the Asian Journal of Andrology in 2011.
Male sex hormones are key to the development of the human penis – and, it’s thought, digit proportion.
Similarly, a 2023 study published in the journal Andrologia found that men with larger noses have longer penises – with the biggest noses, on average, correlating with a stretched penile length of 13.4cm; for smaller noses, it’s 10.4cm.
MEN THINK OF SEX EVERY 7 SECONDS?: This originated from the famous 1948 Kinsey Report on male sexual behaviour. It translates to 8,000 times in
16 waking hours. It was put to the test in a study in 2011 in the US. Students aged 18 to 25 were asked to record their thoughts about sex, eating and sleeping for a week.
The results, published in the Journal of Sex Research, showed that men thought about sex, on average, just 18 times a day – and women, ten.
CERTAIN FOODS ARE AN APHRODISIAC? ‘There’s no food that gives you instant wham-bam desire, but there are ones that can relax blood vessels and improve blood flow in a similar way to Viagra,’ says Emer Delaney, a dietitian based in London.
The benefits centre around their vitamin, mineral and antioxidant content, she explains: ‘L-arginine, found in most protein-rich foods, including fabled aphrodisiac oysters, fish, red meat, wholegrains and dairy products, acts as a vasodilator, opening blood vessels.
Another vasodilator is quercetin, found in red wine, dark chocolate, berries and garlic. Anything with omega 3s can also help, such as oily fish, nuts and avocados, she says.
‘The benefits, however, are only for those with circulatory problems in the first place and the effect won’t be seen overnight.
Hidden signs you’ve got a nasty infection from your partner
There is a huge stigma attached to sexually transmitted infections (STIs), but the fact is numbers are increasing. In 2023 there were 401,800 new cases, an increase of 4.7 per cent since 2022.
While 15 to 24-year-olds are most likely to be diagnosed, analysis by the University of Manchester revealed that STIs are on the rise in older groups, too. Between 2014 and 2019, there were 198,144 new diagnoses in people aged 45 and over.
Part of the problem is that older generations ‘may not have had comprehensive sex education’, says Dr Naomi Sutton, a consultant physician at Rotherham Sexual Health Services.
‘Additionally, when fertility is no longer an issue, it makes condom use – our best protection against STIs – even less likely.’
And on a physiological level, women going through the menopause have thinner vaginal tissue which tears more easily, meaning her partner’s infection is more likely to be transmitted.
‘When you change your partner, develop any new symptoms or want peace of mind, you should get tested for STIs,’ says Dr Sutton. You can do this at your GP or Sexual Health Services, some of which have a drop-in facility.
CHLAMYDIA: The most common STI in the UK, it’s caused by a tiny organism called Chlamydia trachomatis. About 80 per cent of infected women and 50 per cent of men have no symptoms, meaning they carry the infection without knowing.
Symptoms in women include bleeding between periods or after sex, pain in the lower abdomen or burning pain when you urinate; in men, it’s pain when urinating or discharge from the penis tip.
Treatment is with antibiotics. It’s vital to be diagnosed early: left untreated, in women it can lead to pelvic inflammatory disease and infertility. It can cause joint pain in men and women.
GONORRHOEA: Cases of this bacterial infection increased by 50.3 per cent in 2021-2022.
The bacteria can infect the female genital tract and, in both sexes, the urethra, the rectum and less commonly, the throat or eyes. Most women with the infection will have no idea, however there can be bleeding between periods or after sex or increased vaginal discharge.
Up to 10 per cent of men will have no noticeable symptoms, others may have discharge or a burning pain when urinating. Gonorrhoea is now resistant to almost every antibiotic – so careful prescribing is needed at a sexual health clinic, rather than buying antibiotics online.
SYPHILIS: One of the oldest known sexually transmitted diseases, it’s also on the increase – between 2020 and 2021 rates jumped 8.4 per cent.
Caused by Treponema pallidum bacteria, it’s known as the ‘great imitator’, mimicking other conditions so symptoms are easy to miss.
The earliest sign is often a painless sore on the genitals. Later, symptoms can include a body rash (often including the palms and soles) and patchy hair loss.
Left untreated, it can lead to damage to the brain, nerves and blood vessels. Treatment is with an injection of penicillin.
GENITAL HERPES: Caused by the herpes simplex virus (HSV), this infection is very common – about 70 per cent of the population will have been infected by it by the age of 25.
Transmission is through skin-to-skin contact.
Most people have no idea they’re carrying the virus as they’ll never develop any symptoms. The only reliable way to test is when someone has an ulcer and a swab is taken. Antivirals such as acyclovir can help ease symptoms. The virus can ‘hide’ in the body and later reactivate, causing an outbreak.
GENITAL WARTS: Caused by the human papillomavirus (HPV), these can appear months or even years after infection; indeed, some never get warts at all. The warts are typically small, flat and smooth. They aren’t painful but they can itch and bleed, if damaged.
While they may go away by themselves, treatment involves creams such as prescription-only podophyllin (Warticon), freezing therapy or, occasionally, surgical removal.
…WHEN IT’S NOT AN STI
‘Some genital conditions have nothing to do with sex,’ says GP Dr Angela Wright. Thrush is caused by a fungus, candida, that flourishes in warm, moist conditions, when the balance of vaginal microbes changes, as can happen just after a period.
In women, symptoms include white discharge and soreness when urinating. In men, as well as a discharge, it can cause irritation around the penis head and odour.
Anti-fungal medication in the form of a tablet, pessary or a cream, usually clears it. ‘You can use water and an emollient to wash the area, wear cotton pants and pat the area dry,’ says Dr Wright. ‘Don’t use soap or wear tight-fitting underwear.’
Bacterial vaginosis affects around one in ten at some point but half don’t notice. It’s caused by a change in the balance of bacteria in the vagina. It can be distressing due to the quantity of the white discharge and its fishy odour.
These changes can be caused by a new sex partner, douching or even smoking – the chemicals suppress the immune system, which disrupts the balance of vaginal microbes.
It can clear up on its own or require antibiotics.
Exercises to put the va-va-voom in your love life
When muscles are strong and able to fully contract and relax, they help with sexual function
A woman’s pelvic floor forms a hammock across the bottom of the pelvis, supporting the bladder, bowel, uterus and vaginal vault, says Kate Walsh, clinical physiotherapy lead at Liverpool Women’s Hospital.
A similar muscle in men supports the bladder and bowel.
When the muscles are strong and able to fully contract and relax, they help with sexual function – in men, for erectile function and ejaculation; in women, for comfortable sexual intercourse and for optimising sensation.
‘Many of the issues around sexual dysfunction are due to pelvic floor muscles losing the ability to relax,’ says Kate Walsh. ‘It can take months to see results from pelvic floor exercises, but consistency is key – three sessions a day are recommended.
Follow these simple steps:
1 Lie down and imagine trying to stop yourself passing wind; engage the muscles around the back passage drawing them upward and forward.
2 For women, include the muscles around the vaginal opening, as if trying to stop yourself peeing. Try to engage the tummy muscle.
3 For men, tighten and draw in the muscles around the anus and urethra (‘nuts to your guts’). If your technique is correct, you may feel the base of your penis move a little towards the abdomen.
4 Breath is key – as you breathe in, relax the pelvic floor; as you breathe out, engage the muscles. Build strength by increasing the length of time you hold the contraction. Quality is better than quantity; there’s no point holding for ten seconds, if you’ve lost the muscles at two seconds. Focus on releasing fully and resting a few seconds between each contraction.
5 When you’re confident, challenge the muscles by changing position – sitting or standing – then integrate them into your daily activities.
