Sexual Dysfunction in Older Women
Key words: Sexual dysfunction, dyspareunia, vaginal dryness, low libido, vaginismus, vaginitis, vaginal prolapse, estrogen deficiency, hormone replacement therapy.
People experience many physiological and physical changes as they age, some of which can have a negative effect on sexual function. In 1999, sexual dysfunction was estimated to affect approximately 40 million women in the United States,1 and the results of the National Health and Social Life Survey revealed that sexual dysfunction is more prevalent in women (43%) than in men (31%) and that its prevalence increases with age.2 As more baby boomers reach retirement age and life expectancy continues to increase, we expect that the percentage of women experiencing sexual dysfunction will also increase.
Although some older women are not troubled by their loss of sexual desire or their ability to engage in sexual activity, others maintain an interest in preserving their ability to maintain a satisfying sex life. In 2009, Huang and colleagues3 reported the results of their cross-sectional cohort study, which examined sexual function among 1977 women (876 white, 347 Hispanic, 351 Asian, and 388 black) aged 45 to 80 years by having them complete self-administered questionnaires. Of these participants, 43% reported moderate sexual desire and 60% had been sexually active within the 3 months preceding their completion of the questionnaire. This study demonstrates that, contrary to popular belief, many women retain an interest in or engage in sexual activity as they age. Therefore, although sexual issues can be an uncomfortable topic of discussion for both patients and healthcare providers, it is important to address such matters by enabling patients to discuss these relatively prevalent problems, enabling the provision of treatment and resources, if desired.
In women, many more factors contribute to sexual dysfunction than in men, and there are fewer targeted treatments. For example, there are no phosphodiesterase-5 inhibitor equivalents for women. Instead, treatments focus on resolving the issue contributing to or causing the sexual dysfunction, such as vaginal dryness or pelvic organ prolapse. In this article, we discuss some of the common physiological, physical, and social factors that may impact sexual health and contribute to sexual dysfunction. We also review some of the available treatment options.
Factors Affecting Women’s Sexual Health
Numerous factors may impact the ability of older women to have a satisfying sex life. Some of the most drastic changes associated with sexual activity and aging are those that accompany menopause. Estrogen, the primary female sex hormone, affects vaginal wall thickness and lubrication, and decreases in estrogen often produce vaginal dryness and can lead to vaginal atrophy. Weight gain or other body changes that commonly occur in postmenopausal women may also lead to feelings of being less desirable, resulting in avoidance of sexual encounters.
In addition, health problems such as heart disease, diabetes, and depression may contribute to a less satisfying sexual experience as women age. Vascular changes and high blood pressure, for example, can affect blood flow to the clitoris, decreasing the ability to become sexually aroused. Depression is also directly correlated with sexual dysfunction in women.4 In addition, the medications commonly used to treat these and other disorders can also negatively affect sexual arousal. Selective serotonin reuptake inhibitors, mood stabilizers, and tranquilizers are just a few of the medications that have been linked to decreased arousal.5
Another consideration is the loss of a partner or a partner’s illness, which can drastically alter relationships and have a negative impact on sexual activity for both partners. One study found that close to 50% of women aged 45 years and older are either widowed or have no partner, making it difficult for these women to engage in sexual relationships.6
Common Causes of Sexual Dysfunction
Two of the most common causes of sexual dysfunction in aging women are a decreased libido and a decreased ability to achieve climax. In one study, 43% of women ranging in age from 57 to 85 years reported having low sexual desire.7 The study also found that 34% of sexually active women were unable to achieve an orgasm.7 A complex mix of physical, physiological, and psychological factors may contribute to low sexual desire and to difficulty achieving orgasm.
Biologically, the sex hormone testosterone is thought to be responsible for sexual desire, particularly in postmenopausal women. Women’s testosterone production peaks in the mid-twenties and gradually decreases thereafter. This decrease can lead to a decreased libido.8,9 In addition, medications for depression and high blood pressure have also been shown to lower sexual desire by lowering testosterone levels or by decreasing blood flow.10 Medications used to treat many diseases may also lower energy levels, affect a woman’s interest in sexual activity, or change how a woman feels physically, all of which might affect her libido.11 While decreased libido can be found among women of all ages, it is most prevalent in women older than 50 years and after an oophorectomy.12
As previously noted, the inability to achieve orgasm is another important factor that can decrease a woman’s interest in all forms of sex. Vaginal dryness, the result of decreases in circulating estrogen, is one of the most common impediments in a woman’s ability to climax. This condition most often occurs in postmenopausal women, but can also occur during menopause as naturally produced estrogen levels gradually begin to decrease. Vaginitis, with itching or stinging of the vagina, can also impede a woman’s ability to experience orgasm. Vaginitis is caused by microorganisms, most commonly Trichomonas vaginalis, Gardnerella vaginalism, and various Candida species, all of which are more likely to infect women with atrophied vaginal tissue.7,13 An atrophic vagina, or thinning and inflammation of the vaginal walls, may also result from vaginal dryness and lack of estrogen and may create more complex sexual problems, including dyspareunia (painful vaginal penetration) and pelvic pain, which are more difficult to treat.
Along with vaginal dryness, older women may experience decreased vaginal lubrication. During sexual arousal, a natural lubricant is secreted into the vaginal canal in preparation for intercourse, but as women age, decreased estrogen levels and age-related physical changes contribute to decreased secretion of this lubricant. A study of sexual health in US women aged 57 to 85 years found that 39% experienced difficulty with vaginal lubrication.7 When little or no lubrication of the vaginal wall exits, dyspareunia can result. When encountering patients with dyspareunia, clinicians must be careful not to confuse this condition with vaginismus, which is one of the many causes of dyspareunia. Vaginismus is an involuntary contracture of the uterovaginal muscles that is generally attributed to a psychological cause and makes vaginal penetration during sex difficult, painful, or impossible.13 These patients often have a psychological problem or a history of past sexual trauma or abuse. Patients with dyspareunia that is not related to vaginismus report pain in the pelvic area during or soon after sexual intercourse as a result of a physical cause, such as a urinary tract infection, hemorrhoids, vaginal dryness, or an ill-fitting diaphragm.
Another common problem faced by women that may impede sexual function is pelvic organ prolapse, which occurs when one or more pelvic organs descend from their usual position, causing them to bulge into the vaginal canal or the vaginal opening. There are several different types of prolapse, including cystocele, or prolapse of the bladder; urethrocele, or prolapse of the urethra; rectocele, or prolapse of the rectum; enterocele, or prolapse of the small bowel; and uterine prolapse, or prolapse of the uterus. Pelvic organ prolapse has a prevalence rate of 41% among women with an intact uterus and is correlated with certain risk factors, including postmenopausal status (most likely due to a decrease in estrogen needed to maintain the integrity of the uterine wall muscles), an increased number of deliveries, increased body mass index (especially obesity), and straining upon defecation.14 In addition to causing a disruption of normal urinary and bowel function, pelvic organ prolapse can interfere with the enjoyment of intercourse, making women less likely to want to partake in sexual activities due to discomfort or embarassment.15 For example, women with this condition may experience pain and/or urinary incontinence during intercourse, decreased frequency of orgasm during intercourse, and discomfort from protrusion of prolapsed organs into the vagina.
In addition to experiencing physiological and physical problems, older women might undergo personal changes or changes in their relationships that impact their sex life. Feeling emotionally disconnected from a partner can affect the desire to engage in sexual activity. In addition, sex among older couples is often portrayed as a faux pas or as unattractive, which can influence how older women feel about their own sexuality.6 Some women also believe sex is only intended for reproduction, making intercourse after menopause inappropriate.16 Sexual desire and functioning comprise a complex mix of biological, physical, and psychosocial factors, and it is important to take all of these influences into account when treating women who are troubled by their low libido or their inability to engage in or enjoy sexual activity.
Treatments for sexual dysfunction vary, depending on the etiology of the dysfunction, but systemic and topical hormone replacement therapy (HRT) and psychotherapy are the two most commonly used treatment strategies for women with sexual dysfunction that does not have a physical cause, such as pelvic organ prolapse or vaginitis. In the event that the sexual dysfunction is caused by vaginal prolapse, a pessary device or surgical intervention can be considered. In cases of vaginitis, medications that treat the underlying cause are beneficial. What follows is a brief review of some of the treatments that can be used to manage the different causes of sexual dysfunction in women.
Hormone Replacement Therapy
Both estrogen and testosterone HRT may be useful in addressing sexual dysfunction in women older than 50 years. Estrogen is typically prescribed for women with low estrogen levels and/or vaginal atrophy, whereas testosterone is sometimes prescribed to boost libido. Several preparations are available for estrogen therapy, but no form of testosterone has been approved for use in women. Regardless of which HRT is prescribed, numerous safety issues surround the use of these agents.
Estrogens. Many menopausal or postmenopausal women experience symptoms related to low hormone levels, including moderate to severe hot flashes, vaginal dryness, and vaginal atrophy.14 These symptoms can be managed with estrogens given orally, topically, or via vaginal suppositories. Physicians most often prescribe low-dose estrogen administered as a patch or daily pill. Estrogen may also be prescribed as a cream, which is usually used every other day, or as a vaginal ring that releases a consistent dose of estrogen. A vaginal estrogen ring may be considered for women seeking a more convenient treatment option,14 as the ring is usually changed every 3 months. Vaginal discomfort, abdominal pain, and genital itching may occur with the use of the vaginal estrogen ring; however, most women experience no discomfort from the ring, even during intercourse, so it is usually not necessary that the ring be removed. In addition, their partners generally do not feel the ring; thus, its use does not impede sexual function.
Patients should take the lowest dose of estrogen needed to relieve menopausal symptoms. If a woman with an intact uterus decides to take estrogen for postmenopausal symptoms, she should also take progesterone to reduce the risk of developing endometrial cancer. Because oral estrogens enter the bloodstream faster than estrogens contained in topical vaginal creams or suppositories,17 they have more side effects, which may lead to other problems (eg, decreased libido from low testosterone levels). To decrease the risk of side effects, administering estrogens through vaginal suppositories or creams is preferable, as the amount of hormone that is absorbed into the bloodstream is low. Regardless, to reduce cancer risk, doses should be used that have been proved not to increase serum estrogen levels over normal menopausal levels.18 Several studies have shown this level to be 0.3 mg of conjugated estrogens administered vaginally two to three times per week.18 Although this level appears to be safe, it is probably not appropriate for women with estrogen receptor–positive breast cancer to receive this or any other estrogen treatments. In addition, patients with a family history of non-estrogen receptor–positive breast cancer or who have recently had a mass removed, such as an ovarian or uterine cancer, should be monitored closely or avoid taking HRT because estrogen is known to stimulate cancer growth. Finally, estrogens should not be prescribed to treat menopausal or postmenopausal symptoms in women who have normal estrogen levels. These patients should be advised to use an over-the-counter lubricant.
When prescribing estrogens, physicians should also consider their adverse event profile, which varies by preparation. The most commonly reported side effects of conjugated estrogen cream include headache, infection, abdominal pain, back pain, and vaginitis. As for oral estrogens, long-term safety data at 1 year is best established for estradiol tablets, but comprehensive safety data are lacking for all preparations.19
Testosterone. Although testosterone is predominantly a male hormone, women also produce it, and it is needed to sustain a consistent libido in both sexes. Symptoms of fatigue, sluggishness, decreased appetite, and no urge for sexual intimacy may suggest low testosterone levels. The US Food and Drug Administration (FDA) has not approved testosterone use in women, and the long-term safety and efficacy of testosterone in this population have yet to be demonstrated; however, short-term studies (up to 2 years) have shown no increase in the risk of hepatotoxicity, endometrial hyperplasia, behavioral hostility, or cardiovascular effects when serum plasma testosterone levels are maintained at the upper portion or slightly above the normal range in reproductive-aged women.20 It is unclear if these results hold for menopausal and postmenopausal women. Testosterone use may also cause side effects that can negatively impact sexual function by causing undesirable physical changes, such as acne, hirsutism (ie, excessive hair growth in areas where hair normally does not grow), and, upon excessive use, clitoral growth. The bottom line on testosterone treatment is that it may be of some value, but we cannot safely recommend it at this time because it has to be prescribed off label and no reliable studies exist on its use in women, particularly those who are menopausal and postmenopausal.20
Psychotherapy and the PLISSIT model
The way one thinks about sex and the way in which one reacts to different stimuli is psychological in nature; thus, psychotherapy may be useful for treating some cases of sexual dysfunction when physiological and physical causes have been treated or ruled out. For example, psychotherapy may be useful for women with vaginismus who are not responsive to conservative management, such as use of pelvic floor exercises. In such cases, clinicians should consider referring these patients to a sex therapist or a psychiatrist who specializes in treating this condition. When identifying the cause of a sexual dysfunction is a challenge, clinicians can consider using the Permission, Limited Information, Specific Suggestions, and Intensive Therapy (PLISSIT) model.21 This model consists of four phases for initiating and maintaining the discussion of sexuality with older adults (Table).21 The purpose of the PLISSIT model is to help patients gain insight into their sexual feelings and to help them achieve their desired sexual response.
Pessaries and Surgery
When the cause of a patient’s sexual dysfunction is pelvic organ prolapse, pessaries and surgery can be considered. Pessaries are noninvasive devices made of plastic or rubber that are placed in the vagina to support the prolapsed organs. They come in different sizes and styles and can be fitted by a physician to the individual.22 Many pessaries can be worn during sexual intercourse, but they need to be removed and cleaned on a regular basis to prevent them from emitting a foul odor, which can be embarrassing and can impede sexual activity.15,22 In some cases of mild prolapse, estrogen therapy with or without pelvic floor muscle exercises can be tried before prescribing a pessary, or can be used in combination with the pessary.
Surgery is another option, with about 11% of women undergoing some form of surgical repair for pelvic organ prolapse during their lifetime.23 However, before using a surgical approach, it is important to rule out any underlying causes of prolapse, such as obesity or constipation, and to consider concurrent treatment of urinary incontinence, if present.23 When surgical treatment is deemed appropriate, several different surgical procedures are available, including sacral colpopexy, ligament suspension, and graft or mesh placement, and various surgical approaches can be used, including an abdominal, vaginal, or laparoscopic approach. Success rates vary, ranging from 70% to 100%, depending on location and severity of repair, although there are few comprehensive studies on efficacy.23 Surgical complications include erosion, perforation, infection, bleeding, and pain. One study showed a reoperation rate of 29%.23 In addition, recent studies have shown repair with surgical mesh can lead to pain, extrusion, perforation, and dyspareunia, which has led the FDA to release safety warnings about the increased risks associated with transvaginal placement of surgical mesh.24
The true incidence of sexual dysfunction is unknown because the condition may be underreported by both sexes, but one study showed it to be slightly more common in women than in men.2 Problems of decreased libido and an inability to achieve orgasm are two of the most common conditions that affect older women. Healthcare providers should make every effort to ascertain whether such problems are affecting and troublesome to their female patients. They should also remember that numerous factors can contribute to these problems, including physiological and physical problems, psychological barriers, and social issues. All of these factors must be considered and weighed during discussions with patients. Women who wish to have enjoyable and fulfilling sex lives as they age need to know what treatments are available, be educated on how they work, and receive counseling regarding risks and benefits, whereas women who are not interested in engaging in any sexual activity need to know that this is also a valid option.
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The authors report no relevant financial relationships.
Address correspondence to:
Neil Baum, MD
3525 Prytania Street, Suite 614
New Orleans, LA 70115