Would it surprise you if I told you that I treated couples as old as 95? I have! Lately, in fact, I’ve seen several couples in their mid-70’s to late 80s wondering what they are supposed to do about sex.

I’m old, too–but at 62, I’m considered “young old.” (Just for the record, people in their 70s would be considered “old.”) It has been amazing to meet monogamous couples who have been married for 40 to 60+ years who still love and cherish one another, especially here in Orange County where the divorce rate is especially high.

“Old old” couples (those in their 80s and up) have told me that they find this a confusing time for their relationship. They love one another as much, or more than ever, plus they are aware that their lives are finite. They want to enjoy each other now before it is too late. They are seeking comfort, affection, and intimacy. But their bodies are just not cooperating.

Yes, there are medicines to consider. For men, there is Viagra, injection of tri-mix, or even a penile implant. Most men who need testosterone will have it prescribed for them, unless there is a health risk.

For women, there is…well, not much! Women have hormone replacement, but it is meant to be taken for the shortest amount of time possible around menopause to manage symptoms. That means that estrogen is being depleted, leaving vaginal tissues dry. This dryness is upsetting not just physically but emotionally. As natural lubrication stops, intercourse becomes difficult if not impossible.

Women who do not or cannot use hormone replacement therapy may wish to talk to their physician about prescribing topical estrogen. Topical estrogen is most often sold in cream form and it is inserted into the vagina at home using a plunger type applicator. There is also a slow-release estrogen ring that can be left in the vagina for 3 months but it is very expensive, the cream much less so. Because estrogen placed in the vagina does not circulate in the bloodstream, for most women it is considered safe.

But it seems that at some point–a point that may be different for every woman–estrogen cream is only so helpful. The vaginal tissues become so fragile and the pelvic floor muscles so tight (estrogen keeps joints pliable, too) that the whole system just says, “Nope.” It can be more difficult for her to have an orgasm, too. Both things combined, plus hormone status can lead to a total lack of interest in sex.

The honest truth is, though, that many men as they get older find that the oral medications aren’t really doing the trick anymore. They aren’t much interested in injecting their own penis with medication to get an erection. A penile implant is a possibility, but it seems, I think, like a lot of trouble to go through if the female partner isn’t interested. Plus intercourse takes physical energy and stamina that many men in their 80s and 90s simply don’t have.

What to do?

At the top of the list is to ditch intercourse! This may seem obvious to a younger person who is more apt to have experimented sexually with oral and manually sex, e.g., mutual masturbation. But for older, more traditional couples, they feel at a loss if they are unable to continue having sex in the traditional way.

Most often, if the woman feels she has completed the sexual part of her life, what I suggest is that the couple stops struggling and focus on what they can still enjoy. Cuddling, caressing, and holding one another are easier and may be much more satisfying at this stage of life.

If the man is able to have an erection, I talk to the female partner, asking, “Are you willing to stroke him with your hand? Or can he stroke himself while you caress him and tell him you love him?” The same idea can also be considered regarding oral sex. Not surprisingly, the topic of a vibrator for her often comes up. Maybe now it would be a good time to try one to see if she can have an orgasm more easily as well.

There is no shame in coming to the later stages of life and saying that sex/intercourse is no longer pleasurable or desired. After many years of a satisfying sex life, one or both partners should be able to press the “pause” button for a discussion during waking hours while sitting on the sofa. No matter how difficult it may be, the partner or partners need to speak openly and honestly.

Just because penis-vagina intercourse is no longer a desired activity, that doesn’t mean that one partner can pull the plug on the other’s sex life. Instead, couples need to find ways to have a sex life that works for them, even if it looks nothing like the one they had when they first became lovers. For couples like this, even if it is hard to imagine people in their 80s and 90s having sex, they need to find a way to remain lovers until truly death does them part.