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By Penelope Morrison Bosarge, RNC, CRNP, MSN
Women’s Health Nurse Practitioner
Teaching Faculty, Graduate Programs
University of Alabama School of Nursing
There is conflicting research on the effect of menopause on sexual functioning. Some data suggest aging alone is responsible for decreased desire and sexual activity, while others find the changes associated with menopause are responsible. Another predictor of sexual problems in some women was the anticipation of such behavior.1,2
Healthy psychosexual functioning during menopause has many facets encompassing a complex interaction of anatomical, physiological, and psychological factors. Triggering this cascade of events is decreased estrogen. Many women accept sexual problems as the unfortunate consequences of aging and don’t realize menopause plays a role. Thus, they never share their concerns with their health care provider. This column describes changes that may affect a woman’s sexual life as she ages and suggestions that you, as a clinician, can make for successful management.
Anatomical changes include a loss of pelvic support and vaginal strength. The vagina may shorten with constriction in the upper third. These changes may be significant enough to interfere with the enjoyment of sexual activity or may make intercourse difficult, if not impossible. Urethral atrophy along with loss of pelvic support may lead to loss of urinary continence. Vulvar irritation may be a result and cause pain when intercourse is attempted. Pelvic organs may prolapse when vaginal elasticity and ligament strength decline, which allows gravity to take its toll over time.3
Vaginal atrophy can cause dryness, resulting in irritation, burning, and itching with subsequent bleeding and dyparunia. Vaginal lubrication is decreased in volume and viscosity. Up to 60% of women require increased time and amount of stimulation to start lubricating and to produce adequate quantities. Lubrication is often considered the sign of sexual arousal. If not present, the woman or partner may feel she is inadequate to perform sexually. When penetration is attempted, pain and/or burning may occur, which often remains after intercourse is complete.4
Body shape will change, which may be distressing. These changes, which seem to occur overnight, are affected by gravity and loss of elasticity of skin and tissues. Physical appearance plays a role in self-esteem, and thus our sexuality. These changes, if perceived as unattractive, may alter the positive image of our sexuality.
Health problems such as acute and chronic illness may play a large role in how we perform as sexual people. For example, the pain of arthritis or its effects on flexibility may be a factor to consider. Psychological status affects sexuality negatively when depression or other emotional problems are present. Recognition and treatment of these situations may be the solution for many women.
These years that are supposed to be happy and carefree shouldn’t be marred by serious clinical pathology affecting sexual experiences. Recent awareness of the problems and the willingness on the part of patients and health care providers to discuss it openly have led to prevention strategies and successful treatment for many women.
Treatment should take into consideration the woman’s attitudes toward sex. Does she perceive a problem? She may see sex as a marital duty she can happily discontinue at menopause. However, many women continue to have powerful sexual feelings into advancing age but are limited by a disinterested partner or no partner at all.
A concerned health care provider, who has been made aware of the patient’s needs, can help her make choices about treatments. Prevention is always the best treatment. One convenient, successful program of prevention includes hormone therapy. Some researchers claim testosterone and its derivatives show a convincing beneficial effect, with increased sexual satisfaction, frequency of orgasm, and arousal.5 [Use of androgens in post-menopausal women remains controversial. Readers may want to consult pp. 623-624 of Clinical Gynecologic Endocrinology and Infertility (Speroff L, Glass RH, Kase NG. Fourth ed. Baltimore: Williams and Wilkins; 1989) to broaden their knowledge on the subject.]
Estrogen by any route is helpful in preserving or restoring vaginal mucosal thickness and secretions and preventing the negative anatomical changes. Promotion of positive attitudes to aging and menopause, stress reduction, and healthy lifestyles will improve a sense of well-being, which will translate into improved sexual functioning.
Age happens! Our aging bodies can be compared to an older home, where things seem to go wrong all at once. Suddenly there are creaky doors, dripping faucets, running toilets, and sticking doorbells. Proper maintenance of the body, just as with a home, will prevent changes from being so problematic and costly.