Postmenopausal sexual dysfunction

Introduction
The UK has an ageing population. The increasing
number of older people is paralleled by an increase
in diversity of ethnic background.An active sex life
is important to postmenopausal women; failure to
achieve this can have a negative effect on their lives.
Our understanding of female sexual function and
dysfunction is the subject of much debate and
controversy, but it is now recognised that a
woman’s sexual response is different from that of
a man and that this response can change with age.
It is also becoming increasingly recognised that a
woman’s sexual function is highly ‘contextual’ and
the conclusion that many factors can influence
function (physical, psychological, social,
spiritual/religious, pharmacological and
relational) must be accepted.Cognisance must
also be taken of the role that acculturation has on
sexual behaviour—this is the process by which
sexual behaviour changes when one culture
integrates into a different culture. The dynamics
that underpin the resulting behavioural changes
emerge from the interplay between the ‘heritage’
culture and the ‘mainstream’ culture.Women with
postmenopausal sexual dysfunction may present
to a number of different medical disciplines, either
overtly with or without comorbidity, or the
condition may be occult. The challenge to health
workers, therefore, is to diagnose sexual health
problems, to be aware of the myriad of external
influences influencing the sexual response and to
have insight into and understanding of their own
values and assumptions about female sexuality,
which can affect their management decisions.
Demographic and ethnic trends
In 1961 there were 16.0 million people aged
50 years in the UK and in 2002 there were
19.8 million. This number is projected to increase
by 37% by 2031, when there may be approximately
27 million.1 A woman living in the UK can now
expect to live into her 80s.2 The median age of
menopause being 51.3 years,3 this means that a
woman can spend roughly a third of her life in the
hypoestrogenic postmenopausal state. In parallel
with this ageing demographic profile,British
society is becoming more culturally and socially
diverse.4 There is a substantive body of literature
regarding postmenopausal health but, despite the
increasing number of postmenopausal women,
there is limited literature on female sexual
behaviour, function and dysfunction, both
generally (in the cohort studied in this review)
and within cultural subgroups specifically. In
addition, the role of acculturation on sexual
behaviour demands further study.5
The female sexual response
The model that best describes the female sexual
response is still evolving.The seminal work of
Masters and Johnson in 19666 described a linear
sequential model consisting of the phases of
excitation, plateau, orgasm and resolution. This
model and its offspring are criticised for ‘overemphasising
the physiological aspects of sexuality
at the expense of the emotional aspects’.7 It is
accepted that, although the model reflects the male
sexual response reasonably well, it is not applicable
to the female sexual response, as women do not
always move progressively and sequentially
through the phases. It also assumes orgasm as an
end point, but its absence in a woman does not
necessarily imply dysfunction.8
A new model was needed and Basson9 developed
an alternative nonlinear model of female sexual
response which incorporates the importance of
emotional intimacy, sexual stimuli and relationship
satisfaction. In this model ‘the goal of sexual activity
is not necessarily orgasm but rather personal
satisfaction,which can be physical satisfaction
(orgasm) and/or emotional satisfaction (a feeling
of intimacy and connection with a partner)’.8
Summarising the findings from the Melbourne
Women’s Midlife Health Project, Dennerstein10
concluded that the most important factors
influencing middle-aged women’s sexual
functioning were:
• the previous level of sexual functioning
• changes in partner status (gaining a new partner
has a very positive effect,whereas losing a partner
has a negative effect)
• feelings for a partner; and
• the menopausal decline in sexual functioning,
related to the decline in estradiol, which affects
sexual interest, arousal, enjoyment and orgasm
and which can cause dyspareunia.
A new nonlinear model of the sexual response of
women going through the menopausal transition,
incorporating Basson’s9 and Dennerstein’s10
findings, is shown in Figure 1.
Sexual behaviour and sexual
function in older people
In a recent online questionnaire offered on an
independent UK dedicated menopause website,
which was patient-tailored and clinician-led,
92% of postmenopausal respondents reported
that an active sex life was important to them.11 In a
Swedish study Beckman and colleagues12 reported
that the proportion of married women aged
70 years having sexual intercourse had increased
from 38% to 56% and for unmarried women aged
70 years from 0.8% to 12% over a 30-year period
(1971–2001).Marsiglio and Donnelly13 observed
that 24% of people 76 years of age were having
sexual relations more than twice per month.
Lindau and colleagues14 defined sexual activity as
‘any mutually voluntary activity with another
person that involves sexual contact,whether or
not intercourse or orgasm occurs’. In their study
they showed the prevalence of sexual activity
(including sexual intercourse) to decline with age
(73% in the 57–64 years age group, 53% in the
65–74 years group and 26% in the 75–85 years
group were sexually active) but that women were
less likely than men to report sexual activity. They
also recorded that a substantial number of women
participated in vaginal intercourse, oral sex and
masturbation into the eighth and ninth decades of
life. In a recent German community survey,15
libido (sexual desire) was shown to decline with
age and 4.5% of women aged 41–50 years
disclosed lack of libido. This increased to 12% in
the 51–60 years group,with a further increase to
43% in the 61–70 years group and 78% among
women aged 70 years. A web-based survey
undertaken by Cumming and co-workers16
looking at the effect of menopause on women’s
libido among a computer-literate population,
found that 79% of respondents admitted that their
libido was affected by transition through the
menopause and of these 86% felt this was for the
worse.Nappi and Nijland,17 in a European
telephone survey, concluded that cultural values
and health beliefs influenced the perception of
sexuality at the time of the menopause, as well as
the need for treatment,when they described
surprisingly different views towards sex in
different countries within Europe.
Diagnosing postmenopausal
sexual dysfunction
As there is no universally agreed model for the
female sexual response, agreeing criteria for
defining female sexual dysfunction is problematic.
Some commentators have argued that female
sexual dysfunction is the corporate-sponsored
creation of a disease to build markets for new
medications and that sexuality, particularly
hypoactive sexual desire disorder, is judged by
male standards.18 This position does seem to deny
the existence of women’s sexual problems as a
health issue.Nevertheless, the salient point from
this perspective is the danger that sexuality can
become overtly medicalised.Hypoactive sexual
desire disorder will be covered in a separate
article in a future issue of The Obstetrician &
Gynaecologist.
Basson and colleagues19 described a classification
that may prove to be the lingua franca with which
women and clinicians can communicate with each
other and provide a basis and framework for
further research into the prevalence, aetiology and
therapy of female sexual dysfunction. Importantly,
this classification recognises personal distress as
the main criterion for diagnosis (Box 1) and builds
on the existing framework of the International
Classification of Diseases-10 and the Diagnostic
and Statistical Manual ofMental Disorders of the
American Psychiatric Association-IV,which are
based on Masters and Johnson’s model of female
sexual response.
It should also be recognised that inhibition of
sexual desire is not a dysfunction but, in many
situations, the appropriate response for women
faced with stress, tiredness or threatening patterns
of behaviour from their partners.20
The prevalence of sexual
dysfunction
There have been a number of studies looking at the
prevalence of sexual dysfunction among women,but
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New partner Losing a partner
Previous level of sexual functioning
Spontaneous sexual drive
+ve effect -ve effect
Sexual
stimuli
Sexual
Arousal and desire arousal
Satisfaction:
emotional and physical
Emotional intimacy
Decreased estradiol,
↓sexual response
Psychological factors
Figure 1
New nonlinear-model9,10 of female
sexual response during the
menopause transition
the prevalence specifically among postmenopausal
women is unknown.Not only, as has already been
highlighted, are the criteria for diagnosis subject to
debate, so too is the interpretation of the published
studies, which are inconsistent in their
methodology.21
Hayes and colleagues21 calculated the prevalence
of sexual dysfunction using data from 11
published studies. They found low sexual desire
among 64% of participants (range 16–75%)
orgasmic difficulties among 35% of women
(range 16–48%), arousal problems among 31%
(range 12–64%) and pain that interfered with
intercourse among 26% (range 7–28%).
In an American study14 about half of both men
and women who were sexually active reported
at least one bothersome sexual problem, with
the two most prevalent problems among
women being low desire (43%), difficulty with
vaginal lubrication (39%) and inability to
climax (34%).
Cumming and colleagues11 found that 68% of
women hid symptoms of vaginal discomfort from
their partner,with 52% making excuses to avoid
intercourse and 60% admitting that their
symptoms affected their confidence.
Presentation of postmenopausal
sexual dysfunction
Sexual dysfunction can present in a number
of different guises and to different medical
disciplines. It may be presented openly and
without prompting, or after presentation of a
different complaint. There is an increasing
body of literature highlighting the need to ask
direct questions, as women do not generally
discuss sex with a physician.11,14 In addition,
clinicians’ own attitudes can influence how
later-life sex problems are perceived and
managed. In a recent study among general
practitioners,22 ‘many beliefs held about the
sexual attitudes and behaviours of older people
were based on stereotyped views of ageing and
sexuality, rather than personal experience of
individual patients’.
A woman may experience more than one
coexisting sexual dysfunction—symptoms
can overlap. One sexual dysfunction can trigger
or perpetuate another, with a domino-like
effect. For example, pain on intercourse can
lead to avoidance; anticipation of pain can
cause decreased libido, lack of arousal and
loss of orgasm. It is, therefore, important to
determine the primary sexual dysfunction and
how overlapping symptoms have evolved over
time.
Causes of postmenopausal
sexual dysfunction
In reviewing the literature for their guideline on
androgen therapy in women, the Endocrine
Society23 highlighted four factors that correlated
robustly with sexual function/satisfaction. These
were: a woman’s mental and emotional health,
including self-image; her feelings for her
partner; her expectations regarding the future of
the relationship; and her past sexual
experiences. Both natural and surgical
menopauses have the potential to affect sexual
function negatively through poor self-image.
Similarly, previous surgery, including
gynaecological surgery, mastectomy and
formation of a colostomy, can result in loss of
self-esteem, subjective loss of womanhood and
fear of discomfort, thereby having a negative
impact on sexual function.
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Box 1
Classificationa of female sexual
dysfunction
Classification Definition
Sexual desire disorders
Hypoactive sexual desire disorder persistent or recurrent deficiency (or absence) of sexual fantasies/
thoughts and/or desire for or receptivity to sexual activity, which
causes personal distress
Sexual aversion disorder persistent or recurrent phobic aversion to and avoidance of sexual
contact with a sexual partner, which causes personal distress
Sexual arousal disorder persistent or recurrent inability to attain or maintain sufficient sexual
excitement, which may be expressed as a lack of subjective
excitement or of genital (lubrication/swelling) or other somatic
responses, causing personal distress
Orgasmic disorder persistent or recurrent difficulty with, delay in, or absence of orgasm
following sufficient sexual stimulation and arousal, which causes
personal distress
Sexual pain disorders
Dyspareunia recurrent or persistent genital pain associated with sexual intercourse
Vaginismus recurrent or persistent involuntary spasm of the musculature of the
outer third of the vagina, which interferes with vaginal penetration
and causes personal distress
Noncoital pain disorders conditions that interfere with vaginal penetration and cause
personal distress
aEach of these diagnoses is subtyped as A: lifelong versus acquired; B: generalised versus situational; and C: aetiology (organic,
psychogenic, mixed, unknown). Subtyping is based on medical history, physical examination and laboratory tests.
Medical conditions can increase the risk of sexual
dysfunction.24 Depression is common among
menopausal women and often lowers libido.
Diabetes lowers sexual arousal and orgasm and
untreated thyroid disease is associated with
decreased libido which generally resolves with
treatment. Ischaemic heart disease or previous
myocardial infarction can impair arousal because
of apprehension about causing a subsequent
cardiac event. Some common medications can
adversely affect sexual function;24 these include
antidepressants and antihypertensives and they
can be associated with reduced sexual interest,
diminished arousal and difficulty reaching
orgasm.Anticholinergics can cause decreased
lubrication.
Menopause is characterised by a hypoestrogenic
state and reduced testosterone levels. Estrogen
acts on receptors in the brain, breast, vagina,
vulva, urethra and neck of the bladder. The
lack of estradiol can lead to a variety of
symptoms, many of which can cause or
contribute to sexual dysfunction. Estrogen
deficiency may be associated with hot flushes,
mood changes, disturbed sleep, erratic
menstruation, urogenital problems, increased
vaginal pH and diminished pelvic muscle tone
and intraurethral pressure.Vaginal dryness
results from reduced vaginal secretions,
which may lead to dyspareunia, vaginitis and
vaginismus. Decreased stimulation of the
estrogen receptors in the vagina can lead to
atrophic changes; the vaginal mucosal
epithelium becomes thinned and the vaginal
walls and vulva become pale, thinner and less
elastic. This reduced resilience of the pelvic
tissues can lead to intercourse being
uncomfortable. Sensory perception can also
be impaired, leading to increased sensitivity
to touch and pain.25,26
The postmenopausal ovaries secrete more
testosterone (50%) than the premenopausal
ovaries (25%).However, the overall production
of androgens is reduced owing to a decrease in
adrenal production of dehydroepiandrosterone
and its sulfate. This decrease in androgens can
have numerous effects, including fatigue and
diminished sexual motivation, fantasies,
enjoyment and arousal.26 The Endocrine
Society23 recommend against ‘making a
diagnosis of androgen deficiency at this time
because there is neither a well defined clinical
syndrome nor normative data on testosterone
or free testosterone concentrations in the blood
that can be used to define the disorder’. This is in
contrast to the earlier Princeton consensus
statement on female androgen insufficiency,27
which defined it as a pattern of clinical
symptoms in the presence of decreased
bioavailable testosterone and normal estrogen
status. The debate continues.28
Management of
postmenopausal sexual
dysfunction
The aim is to maintain a healthy sex life within the
constraints of age-related changes in sexual
function.These goals need to be considered
together with the age-related changes in the male
partner; expectations from sexual interaction may
need to be modified to accommodate the effects of
comorbidities and treatments.
Goldstein29 recommends a five-part diagnostic
and treatment algorithm to aid clinical
management (Box 2) which ‘engages mind, body
and relationship issues and proceeds in a rational
and cost-effective fashion from diagnosis,
education and counselling through modification
and then to first- and second-line treatment’.
Psychosexual counselling in particular is one of
the mainstream primary approaches and has well
proven success rates.30
It is not completely clear how the decline in levels
of estrogen and progesterone and the role of
testosterone relate to female sexual functioning
as ageing progresses. It is recognised that
estrogen replacement therapy will restore
vaginal epithelial function, improve vaginal
flow and increase the sense of well-being. It should
be noted that 10–25% of women taking systemic
estrogen may have urogenital atrophy and the
addition of vaginal estrogen is appropriate.31 The
role of testosterone replacement therapy is less
clear.
Conclusion
Sexual problems among postmenopausal
women are common and the causes are
multifactorial; the diagnosis of female sexual
dysfunction is, thus, complex and often difficult.
It may be that female sexual dysfunction
represents a silent epidemic. The clinician needs
to be aware of all the potential influences,
including their own prejudices and perceptions.
Treatment involves a holistic multidisciplinary
approach, including counselling, psychosexual
therapy and pharmacotherapy. There is no
universal panacea.
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