This article has been cited by other articles in PMC. Abstract Although sexuality remains an important component of emotional and physical intimacy that most men and women desire to experience throughout their lives, sexual dysfunction in women is a problem that is not well studied. Increasing recognition of this common problem and future research in this field may alter perceptions about sexuality, dismiss taboo and incorrect thoughts on sexual dysfunction, and spark better management for patients, allowing them to live more enjoyable lives.
This need is especially acute for physicians who will increasingly encounter patients trying to maintain a high quality of life as their bodies and life circumstances change, and as advances in nutrition, health maintenance, and technology allow many to extend the time midlife activities are maintained.
One quality-of-life issue affected by these changes, for both men and women, is sexuality. Although studies agree that the majority of women consider sexuality a very important determinant of quality of life, the literature on the subject of sexual function in elderly women is not extensive. Background Although sexuality remains an important component of emotional and physical intimacy that most men and women desire to experience throughout their lives, it is unfortunately a topic many health care professionals have difficulty raising with their patients.
Thus, it is not surprising that sexual dysfunction is a problem that is not well studied or discussed. Common disorders related to sexual dysfunction and increasing age include cardiovascular disease, diabetes, lower urinary tract symptoms, and depression. Treating those disorders or modifying lifestyle-related risk factors eg, obesity may help prevent or diminish sexual dysfunction in the elderly. Estrogen Deprivation Estrogen plays an essential role in female sexuality.
One role of estrogen is to promote pelvic tissue resiliency for comfortable intercourse. When estrogen is not produced at a level sufficient to maintain premenopausal levels, vaginal dryness may occur. Furthermore, inspection of the vaginal tissues in postmenopausal or otherwise estrogen-deficient women reveals the mucosa to be dry and thin.
A reduction in the amount of pubic hair and loss of subcutaneous fat and elastic tissue causes the labia majora and minora to appear wrinkled. Additionally, chronic estrogen deprivation causes the labia to become less sensitive to tactile stimulation. Heightened anxiety can cause dyspareunia by decreasing blood flow to the vaginal area. Pelvic atrophy, bony pelvis, decreased vaginal lubrication, greater irritation, tissue friability, and anxiety may result in pain or abdominal discomfort with both insertion and deep penetration.
There is a lack of elasticity and tone of these tissues. Such changes can lead to urinary incontinence, urinary frequency, dysuria, and cystitis after intercourse. These problems account for substantial morbidity among post-menopausal women. In response, the levels of gonadotropins rise between 5- and fold. When SHBG production increases the level of free testosterone decreases; this is commonly seen in aging women. Treatment with transdermal testosterone combined with an oral conjugated equine estrogen improved sexual function and psychologic well-being substantially more than placebo treatment.
Sexual Dysfunction The traditional linear cycle of female sexual response was first constructed by Masters and Johnson. It is composed of four phases: In this model, desire leads to arousal then to plateau, which is followed by orgasm and resolution. This model was intended to reflect sexual response for men and women; however, researchers recognized that some women did not experience all four phases of the cycle. The woman assesses her subjective arousal by how sexually exciting she finds the stimulus and by concurrent emotions and cognitions generated by the arousal.
This modulation of her subjective arousal appears to be more consistent than the variable modulation by feedback from the genital vasocongestion. Sexual satisfaction may occur without orgasms. Alternatively, orgasms may be experienced before the maximum arousal, and further orgasms may occur at peak arousal and during its very gradual resolution.
Thus, for women, orgasm and arousal are not particularly distinct entities. It has a major impact on quality of life and interpersonal relationships. Despite the widespread interest in research and treatment of male sexual dysfunction, less attention has been paid to the sexual problems of women. Selection of medications should take into account sexual dysfunction and patient desire to improve sexual activity. These disorders are subclassified as hypoactive sexual desire disorder HSDD , sexual aversion, female sexual arousal disorder, female orgasmic disorder, and sexual pain disorder, encompassing dyspareunia and vaginismus.
When a woman describing lack of libido has really never had much interest in sexual activity, treatment is less likely to be successful.
The cause is not considered to be hormonal because libido was lacking in these women even when estrogen and testosterone were at premenopausal levels.
Some postulated theories are early abuse, relationship difficulties, or psychologic factors such as depression. Sexual arousal disorder is the persistent or recurrent inability to attain or maintain sufficient sexual excitement that causes personal distress, which may be expressed as a lack of subjective excitement, lack of genital lubrication, or some other somatic response.
Orgasmic disorder is the persistent or recurrent difficulty, delay in, or absence of attaining orgasm following sufficient sexual stimulation and arousal that also causes personal distress. Psychologic issues, antidepressants, alcohol use, and drugs have all been responsible in causing anorgasmia. The most common causes are infection, surgery, medications, endometriosis, and interstitial cystitis. Vaginismus is the recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with vaginal penetration that causes personal distress.
Noncoital sexual pain disorder is recurrent or persistent genital pain induced by noncoital sexual stimulation. Sexual Dysfunction and Age Multiple factors determine female sexuality and libido. These include the health of the individual, her physical and social environment, education, past experiences, cultural background, and her relationship with her partner.
Sex and sexuality after the age of 60 years may be affected by both individual physical changes of aging as well as the physical changes of aging in her partner. Aged women may be more concerned about problems related to intimacy, 16 dyspareunia, decreased arousal and response, decreased frequency of sex, and loss of sexual desire.
There are eight assessments using a self-reported questionnaire based on the McCoy Female Sexuality Questionnaire and blood samples for hormone levels. By the postmenopausal phase there was a significant decline in sexual arousal, interest in, and frequency of sexual activities.
Participants were aged 42 to 52 years, pre- or early perimenopausal, and not using hormonal therapies. Early perimenopausal women reported greater pain with intercourse than premenopausal women, but the two groups did not differ in frequency of sexual intercourse, desire, arousal, or physical or emotional satisfaction. Variables having the greatest association across all outcomes of sexual function were relationship factors, the perceived importance of sex, attitudes toward aging, and vaginal dryness.
The results were similar, illustrating that pain during sexual intercourse increased and sexual desire decreased over the menopausal transition. Masturbation increased during the early transition, but then declined in postmenopausal women.
The menopausal transition was not independently associated with reports of the importance of sex, sexual arousal, frequency of sexual intercourse, emotional satisfaction with partner, or physical pleasure. Therapies to prevent menopausal transition-associated vaginal pain may help slow or prevent subsequent declines in sexual desire.
The very strong association of the importance of sex with all domains of sexual function suggests that asking women about the importance of sex may be the cornerstone in the management of sexual concerns of aging women.
A study of Sexuality and Health among older adults in the United States sampled US adults, women and men, aged 57 to 85 years, and described the association of sexual activity, behaviors, and problems with age and health status. All agree that elderly women engage in, or wish to engage in, sexual activity.
Some studies cite a decrease in sexual behavior and interest with age, 19 , 26 whereas others find no decrease. All members of the WHI observational study, aged 50 to 79 years—excluding women who did not respond to the sexual satisfaction question or reported no partnered sexual activity in the past year—were included.
After controlling for a wide range of variables, black women reported a higher frequency of sexual intercourse than white women; Hispanic women reported lower physical pleasure and arousal; Chinese and Japanese women reported more pain and less desire and arousal than white women, although the only significant difference was for arousal.
Organic Causes of Sexual Dysfunction Many common general medical disorders negatively impact sexual function, causing decreased interest in sex Table 1. Negative effects on desire, arousal, orgasm, ejaculation, and freedom from pain during sex can occur.
Chronic disease also interferes indirectly with sexual function by altering relationships and self-image and causing fatigue, pain, disfigurement, and dependency.