Abstract
The importance of female sexual fulfillment is increasingly recognized in today's society. Women's sexual lives continue well into the menopausal years and beyond; however, the impact of menopause on the quality of that sexual life has not been comprehensively studied in the medical literature. This review attempts to clarify the impact of the physiological, psychological and psychosocial changes occurring at midlife that may affect women's quality of sexual life. Pharmaceutical and psychological interventions that may assist in improving the quality of sexual life of menopausal women are discussed. Female sexuality is complex and not fully understood and, consequently, controversy frequently arises in the discussion of female sexual problems and their treatment. This article highlights some of these controversies and provides a future perspective on how the impact of menopause on the quality of sexual life may be more cohesively investigated.
Keywords
The recent surge of medical interest in the sexuality of menopausal and older women reflects a wider cultural shift in the attitude towards female sexuality. The perception that the end of a woman's reproductive years equates to the end of her sexual life has been replaced by the knowledge that satisfying sexual activity can, and does, continue into the menopause and beyond. This change in attitude may be driven partly by increasing scientific understanding of the human sexual response and the search for a ‘female Viagra’ to match the commercial success of the male impotence drug, and partly by the characteristics of the ‘baby boomer’ generation, who are perhaps more likely than the previous generation to demand that their health, and indeed sexual needs, be met [1].
Investigation into the prevalence of sexual activity in the menopausal population as distinct to the aging population appears to be rarely quantified, as studies tend to assess the prevalence of sexual activity in terms of age rather than menopausal status. However, a recent cross-sectional study of the sexual activities and behaviors of 2109 women aged 40–69 years indicated that approximately 75% were sexually active [2]. Such data provide evidence that a substantial proportion of the female population are sexually active around the age of menopause and that their sexual needs are worthy of attention from the healthcare profession.
It is often easy to assume that middle-aged and older patients may be reluctant to discuss their sexual lives with healthcare practitioners. A recent analysis of the attitudes of General Practitioners in the UK revealed that many have the tendency to consider that sexual health may not be a ‘legitimate’ topic for discussion [3], whereas a number of studies indicate that, in fact, a significant proportion of middle-aged and older people would welcome enquiry into their sexual wellbeing [4–6].
The overall aim of this review is to use the current literature to assess the impact of menopause on women's quality of sexual life. Quality of sexual life is a term used to encompass aspects such as the absence or presence of bothersome sexual problems, sexual satisfaction and sexual wellbeing, and is inherently subjective. As will be outlined in this review, it is essential to remember that the presence of sexual problems is not synonymous with poor quality of sexual life [6].
In preparation for this review, no single piece of research was found that comprehensively investigates the impact of menopause on quality of sexual life. Instead, the majority of literature concentrates either on how menopause affects overall quality of life or the impact of menopause on sexual function, with most studies failing to adequately distinguish between the presence of a sexual dysfunction and poor quality of sexual life. Consequently, this review is an attempt to elucidate the impact of menopause on quality of sexual life from the information that can be gleaned from the current literature. It is not intended to be a systematic review.
In order to provide context and to introduce the difficulties associated with the assessment of the quality of sexual life in menopause, the available data on the prevalence of sexual activity and sexual problems in the menopausal population are outlined. The aim of this article is then to introduce the hormonal physiological changes of menopause, the symptoms associated with them and their impact on overall quality of life and quality of sexual life, followed by a discussion of the psychosocial aspects of menopause and midlife that may also bring about a change in quality of sexual life. Details of, and evidence to support the use of, specific therapeutic interventions aimed at improving middle-aged women's sexual lives are outlined.
Menopause: definitions & epidemiology
Menopause is defined as ‘the permanent cessation of menstruation resulting from loss of ovarian follicular activity’ [7]. In the majority of women, menopause is a natural event occurring, on average, at the age of 51.3 years [8]. An earlier menopause may be induced surgically by oophrectomy, often accompanied with hysterectomy, or as a consequence of premature ovarian failure.
The time at which natural menopause is said to have occurred for an individual is a retrospective clinical diagnosis based on 12 months of amenorrhea from the woman's last menstrual period [9]. Natural menopause is not a singular event but a transition lasting on average 3.8 years [8]. The transition begins with the perimenopause and this period, often referred to as the climacteric, commences at a mean age of 47.5 years [8]. The menopause transition can be divided into early transition and late transition (also known as early and late perimenopause); early postmenopause and late postmenopause, with each stage marked by changes in hormonal status producing patterns of ‘menopausal’ symptoms [9].
Prevalence of sexual activity, sexual problems & sexual dysfunctions in menopausal women Sexual activity in menopausal women
As discussed previously, most studies investigating the prevalence of sexual activity tend to differentiate groups of women according to age rather than by menopausal status. In the previously mentioned study, which demonstrated a prevalence of sexual activity of 75% in the female group aged 40–69 years, approximately two-thirds of those who were sexually active expressed some level of satisfaction with their sex life [2,10], which is approximately equal to rates of satisfaction recorded in younger women.
A recent cross-sectional study of the sexual activities and behaviors of 3005 men and women aged 57–85 years across the USA, indicated that 73% of people aged 57–64 years, 53% aged 65–74 years and 26% of people aged 75–85 years were sexually active [11]. Self-reported health was a significant predictor for sexual activity in both men and women, indicating that health problems are often a barrier to sexual activity. For women in this study, the most common reasons for sexual inactivity were having a male partner with a health problem (64%) and female lack of interest in sex (51%) [11]. The study further concluded that the importance attributed to sexual activity appears to decline with increasing age [11], and women who are sexually inactive generally tend to consider sex to be less important [11,12].
Whilst these results clearly refer to a population that is beyond the age of menopause, they confirm that although sexual activity declines with age, a substantial proportion of older adults are sexually active, consider sex to be an important aspect of life and are satisfied with their sexual wellbeing. It would be interesting to determine whether the reasons given for sexual inactivity also apply to the menopausal population.
Investigation into the prevalence of, and satisfaction with, sexual activity leads onto the study of problems with female sexuality that may interfere with sexual activity and their influence on sexual wellbeing.
Problems of sexual function versus female sexual dysfunctions in menopausal women
The medicalization of female sexuality is a subject of much contention and debate, with disagreement on the definitions, and therefore prevalence, of female sexual problems taking center stage.
Female sexual dysfunction (FSD) is the medical term given to problems with the female sexual response, which can impact on perceived quality of sexual life. Master and Johnson's four-phase model of the female sexual response is the basis for the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), which classifies FSDs into:
Sexual desire/interest disorders (including hypoactive sexual desire disorder [HSDD] and sexual aversion disorder);
Sexual arousal disorders (problems with lubrication/genital sensation);
Orgasmic disorders;
Sexual pain disorders (including dyspareunia and vaginismus) [13].
The recent redefinition of FSD in the DSM-IV allows for FSDs to be distinguished from ‘problems of sexual function’ by the inclusion of ‘marked distress and interpersonal difficulty’ [14], which is required for the diagnosis of FSD – an important distinction that becomes apparent when trying to assess the impact of FSDs on a patient's quality of sexual life.
Hayes and Dennerstein compared the prevalence outcomes for FSDs using a validated instrument that measured personal distress, the Female Sexual Distress Scale (FSDS), in combination with the validated Sexual Function Questionnaire (SFQ) versus employing the SFQ alone and found that, across all types of FSDs, including personal distress via the FSDS yielded lower prevalence rates. Specific examples include a prevalence of 16% (FSDS plus SFQ) versus 48% (SFQ) for problems with low desire and 8 versus 25% for difficulties with orgasm [15].
In Hayes and Dennerstein's critical review of community-based studies that investigate the impact of aging on sexual function and dysfunction in women [16], analysis of cross-sectional studies demonstrated that increasing age does appear to bring about a decline in sexual function, specifically in the areas of desire, sexual interest and frequency of orgasm [16]. Perhaps surprisingly, the prevalence of FSDs was observed to remain fairly constant with increasing age, with the exception of pain, which appeared to decline with increasing age [16]. Longitudinal studies analyzed in this review confirmed a decline in the frequency of sexual activity with age, but also confimed that sexual interest/desire remains relatively stable [16].
Hayes and Dennerstein's review concluded that the overall prevalence of FSD remains constant with age, and they tentatively concluded that this may be due to age-related changes in sexually related personal distress [16] – that is to say, whilst problems of sexual functioning increase with age, this may be compensated for by decreasing levels of distress within this area of women's lives.
The authors noted that further evidence was required to support this theory and went on to specifically investigate the relationship between HSDD and aging [17], using validated instruments to measure sexual desire and sexual distress in a group of 1998 European women aged 20–70 years. In women aged 20–29 years the proportion with low desire was 11%; in the 60–70 year old group the proportion with low desire was 53%. In the younger group, the proportion distressed by low sexual desire was 65%, whereas in the older group it was 22%. Consequently, the authors concluded that prevalence of HSDD remains essentially constant with age [17].
Prevalence of FSDs in menopausal women
The prevalence of FSD across all ages is generally reported to be 20–50% [14]. As with the prevalence data for sexual activity, most studies examine rates of FSD according to age and do not distinguish the effects of aging from those of menopause status, with some notable exceptions [18,19].
Examples of studies on middle-aged and older women report prevalences of FSD between 33% [2] and 51% [20]. Prevalence of specific FSDs also demonstrates variation; rates for desire/interest disorders range from 6 to 43%, [6,11,17] and orgasmic disorders have been variously reported as having a prevalence of 23–34% [6,11].
Dissection of the differing definitions, methods and instruments employed in assessing the prevalence of female sexual problems reveals the source of the variation: studies conducted prior to the development of validated instruments, and before the definitions of sexual dysfunctions that incorporate personal distress were adopted, clearly have the potential to distort the prevalence data, as does study design (e.g., cross-sectional, longitudinal, prospective or retrospective), use of a validated measure of sexual function, sample size and the population being investigated (e.g., community or clinic based).
Such variable data highlights the difficulties of determining the true prevalence of FSDs and cautions the clinician regarding the dangers of assuming that the presence of female sexual problems equates to distress, dissatisfaction and poor quality of sexual life.
Menopause physiology, symptoms & impact on quality of life
Menopause: hormonal physiology
The hormonal outcome of the menopausal transition is a decrease in levels of estradiol and an increase in follicle-stimulating hormone with the late perimenopause and early postmenopause being the period over which the majority of change occurs [21]. Sex hormone-binding globulin (SHBG) and inhibin (A and B) also decrease towards postmenopause. Total testosterone decreases with increasing age throughout women's lives, with the peak decline occurring at the age of 30 years [21] and little variation occurring across the menopause transition, although free testosterone increases towards postmenopause owing to decreasing SHBG. Levels of dihydroepiandrosterone sulphate (DHEAS), a precursor to both estrogens and androgens, decrease with increasing age but are not associated with menopause status [21]. In menopause induced by bilateral oophrectomy, levels of estradiol and total testosterone decline sharply, resulting in more severe symptoms.
Impact of menopausal hormonal physiology on sexual function
As previously outlined, the most common sexual complaints occurring around the time of menopause onset are lack of sexual desire or libido, lack of sexual arousal and vaginal dryness. The female sexual response is complex and is not yet fully understood, but the hormonal changes of menopause have been suggested to affect the sexual response through a variety of mechanisms, some of which have been more conclusively demonstrated than others.
Estrogens are responsible for maintaining the collagen, elastic fibres and vasculature of the urogenital tract that is essential for its structural and functional integrity. This hormone also maintains vaginal pH and moisture levels, keeping the tissues lubricated and protected. Prolonged estrogen deficiency, as occurs in menopause, results in atrophy, fibrosis and reduced blood flow to the urogenital tract [13], causing the symptoms of vaginal dryness, soreness and pain related to sexual intercourse dyspareunia).
Dennerstein et al. tracked the serum estradiol levels of 226 Australian women aged 45–55 years, who were still menstruating at baseline, across the menopause transition and compared estradiol levels with scores indicating sexual function. They found that women with low sexual function scores had lower estradiol levels compared with those with higher scores, particularly in the area of vaginal dryness and dyspareunia [22].
The role of androgens in the female sexual response is particularly unclear and controversial. Suggested symptoms of androgen deficiency in women include decreased libido, fatigue and a reduced sense of wellbeing. Some studies support an association between low free-testosterone levels and low libido [23], whereas others show no correlation between testosterone levels and sexual function [22,24,25]
Davis et al. compared serum levels of total and free testosterone, androstenedione and DHEAS in a cohort of 1021 women aged 18–75 years against validated measures of sexual function [24]. This study concluded that there was no clinically significant link between having low serum total testosterone, free testosterone or androstenedione and sexual function. However, there was a significantly increased likelihood of having low serum DHEAS and poor sexual responsiveness in older women [24]. Gracia et al. found a similar association between decreased serum DHEAS levels and decreased sexual function [26]. Alternative studies have found no correlation between DHEAS and sexual function [22].
Symptoms of menopause
A wide variety of symptoms have been linked with the menopause transition that may have a detrimental effect on a woman's quality of life, and directly, or indirectly, affect her sexual life. It is important to note that not all women will experience these symptoms [27] and that those who experience symptoms may not necessarily find the symptoms bothersome.
The most frequently reported symptoms that are popularly attributed to the menopause include vasomotor symptoms, such as hot flushes and night sweats, and urogenital problems, such as vaginal dryness or soreness [9,28]. Other complaints include sexual dysfunctions, such as low libido, incontinence, somatic aches and pains, fatigue and sleep disturbances, mood changes, such as increased irritability, cognitive changes, such as forgetfulness, and psychological disturbances, such as anxiety and depression [9].
As discussed in this review, which of these symptoms result from the menopause transition itself, and which result from the aging process or other factors, including prior health and psychosocial factors, is a subject of much clinical research. The current consensus of the NIH is that only hot flushes, night sweats and vaginal dryness can be conclusively linked to menopause, with some evidence of a link between menopause and sleep disturbance [27].
Vasomotor symptoms
A total of 75% of women have been demonstrated to experience a bothersome hot flush at some time during the menopausal transition [21] with the incidence found appearing to vary with menopausal status. In premenopausal women, the incidence of vasomotor symptoms is reported to be 21%, increasing to 38% in early perimenopause, reaching a peak of 55% in late perimenopause and then declining to 44% in postmenopause [29]. Ethnicity also impacts on the reporting of symptoms with African–American women most likely to report vasomotor symptoms and Chinese and Japanese women the least likely to report symptoms [29].
Urogenital symptoms
The link between urogenital symptoms (e.g., vaginal dryness, soreness and dyspareunia) and menopause transition is clear, with vaginal dryness in particular increasing from early to late perimenopause by 13–16% [29].
Mood disturbances & depression
The cultural stereotype of the menopausal woman as moody and irritable may stem from the commonly held belief among women and physicians alike that menopause causes depression and negative mood. However, evidence of a direct link between menopausal status and depression appears to be conflicting in the present literature, with some studies supporting a link [30], others finding only a modest increase in depression [8] and further studies concluding that from early to late menopause transition, negative mood improves and positive mood does not change [21].
Analysis of data from the Massachusetts Women's Health Study (MWHS), a prospective study of 2565 women aged 45–55 years, indicates that prior depression is the variable that is most predictive of subsequent depression in menopause [8]. This conclusion is supported by findings from the Melbourne Women's Midlife Health Project (MWMHP), another significant prospective study of 438 women aged 45–55 years, which concluded that the magnitude of negative mood in menopause is determined by prior experience of negative mood [21]. Other factors demonstrated to be predictive of depression in menopause include severe menopausal symptoms, high stress and daily hassles, negativity towards their partner, cigarette smoking, low exercise and poor self-reported health [8,21].
Such findings are highly relevant to clinical practice, indicating that it should not be automatically assumed that depression in midlife women is due to the menopause, and other possible contributors to depression should be considered and addressed [31].
Effect of menopausal symptoms on overall quality of life
Initial small, patient-based studies have indicated that women felt their quality of life was severely compromised by menopausal symptoms [32] and further studies concluded that menopause brings about a significant decrease in quality of life that is independent of other factors, such as age, marital status and other sociodemographic variables [33]. Research from the MWMHP revealed a temporary decrease in wellbeing associated with increasing menopausal status, with the lowest wellbeing recorded in women 1–2 years postmenopause. This was only transitory, with a return to increased levels of wellbeing recorded in those more than 2 years postmenopause [34].
Alternative research from practice-based populations, using validated instruments and cross-sectional design, has demonstrated that quality of life is mainly influenced by socioeconomic and cultural factors, rather than menopause itself [35]. Prospective, longitudinal research conducted as part of the Study of Women's Health Across the Nation (SWAN) indicates that menopausal status and symptoms do not affect quality of life, the strongest predictors for quality of life being stress and marital status, with attitude towards aging a contributing factor [36].
Psychosocial aspects of menopause, midlife & beyond
Aside from having to contend with potentially bothersome menopausal symptoms, many women experience personal and social changes at midlife, which appear, as already indicated, to affect quality of life and sexual wellbeing to a greater extent than the presence of menopausal symptoms or sexual problems. Psychosocial aspects of midlife and aging affecting quality of sexual life include personal and cultural attitudes towards menopause and aging, psychological issues and relationship factors.
Attitude to menopause & impact on quality of sexual life
Women's attitudes towards menopause and aging will impact on health-seeking behavior, perceived quality of life [36] and sexual practises. Studies indicate that, despite the focus on the negative aspects of menopause encountered in healthcare practice [37], the majority of women in modern Western society have an overall neutral or positive attitude towards the experience of menopause and aging [38,39], with the SWAN study finding that African–American women have the most positive attitudes [38]. This is attributed to African–American women's greater exposure within family groups towards the realities of menopause, as opposed to the stereotypes and negative expectations that may be more pervasive in other cultures [38].
One positive aspect of menopause frequently reported in the literature is ‘an increased sense of freedom’, variously meaning freedom from fear of pregnancy, from menstruation, from childcare responsibilities and freedom to concentrate on one's own needs [37–39]. Caucasian and African–American women are the cultural groups most likely to report an increased sense of freedom, and this may be attributed to the high value placed on female independence in these cultures [38]. Interview studies conducted amongst menopausal women suggest that freedom from pregnancy and menstruation improve women's sexual life [39], indicating that despite the impact of menopausal symptoms on sexual function, sexual confidence and wellbeing can improve with age and menopausal status.
Psychological issues at midlife
Issues identified as impacting on women's psychology around midlife include adult children leaving home (the so-called ‘empty nest syndrome’), career changes, stresses, such as caring for elderly parents, and the development of poor body image and low self esteem.
Changes to a woman's perceived role in life as well as the physical changes associated with aging and menopause have been demonstrated to contribute to women's self esteem at midlife and impact on physical and psychological health; women with high self esteem tend to experience fewer menopausal symptoms [40].
Impact of relationship factors on quality of sexual life
Midlife is a time for potential changes to women's intimate relationships, including the loss of a partner through death or divorce; a change in attitude or feelings towards a partner, or the physical, sexual and psychological problems experienced by the partner.
The impact of relationship factors on the quality of sexual life of older women should not be underestimated, with a number of studies citing relationship factors as having a great effect on global and sexual quality of life, independent from or in excess of menopausal factors [36,41–43]. The majority of studies focus exclusively on heterosexual relationships.
Dennerstein et al. measured the effect of relationship factors on sexual function throughout the menopause transition and concluded that although the primary predictor of female sexual response (which includes sexual interest, arousal, interest, enjoyment and orgasm) is prior sexual functioning, remaining with or changing sexual partners as well as feelings towards partners, are also key to sexual response [41].
Health and sexual problems relating to male partners have been identified as a significant cause of abstinence in midlife and older women [11]. Analysis of results from the Massachusetts Male Aging Study found that the risk of erectile dysfunction in men aged 40–69 years was 26 cases per 1000 men annually, with the risks increasing with age and the presence of comorbidities, such as diabetes, heart disease and hypertension [44]. The introduction of male impotence treatments can bring about further changes to an older couple's sexual relationship; women may have difficulty adjusting to the reintroduction of sexual activity into the relationship [45] or welcome the return to sexual life (
Interventions for menopausal women seeking an improvement in quality of sexual life
Interventions that are focused on the management of menopausal women who report concerns with their sexual wellbeing fall into two broad categories: pharmacological treatments that are aimed at ‘correcting’ menopausal hormonal deficiencies or psychological interventions aimed at treating the psychosocial and relationship factors that impact on quality of sexual life at middle-age.
Pharmaceutical interventions
The idea that a simple pill can fix women's sexual problems, and thus improve their quality of sexual life, is an attractive prospect for both the women concerned and the pharmaceutical industry, which seems to be constantly searching for the ‘female Viagra’.
Estrogen deficiency & HRT
The mainstay of pharmaceutical treatment of menopausal symptoms is HRT. Systemic estrogen replacement therapy (either oral or transdermal patch) is conclusively demonstrated to treat the bothersome symptoms of menopause caused by deficiency of estradiol, namely vasomotor symptoms and vaginal dryness, which impact on sexual function (National Institue Consensus). Evidence that estrogen replacement improves mood or cognitive symptoms is weak [27] because, as previously mentioned, these symptoms are strongly associated with lifestyle and psychological factors rather than the hormonal changes of the menopause transition.
Preparations for HRT may contain estrogens alone or a combination of estrogen and progesterone. Combined HRT is recommended for women who have not undergone hysterectomy, owing to the risks of endometrial cancer associated with unopposed estrogen therapy. Topical estrogens are available as gels and creams that can be applied locally around the vulva or as ring pessaries placed inside the vagina to treat vaginal dryness and atrophy, which may interfere with sexual function [46].
With regard to specific FSDs and the treatment benefits of HRT, Gonzales et al. compared the prevalence of FSDs in 231 women aged between 40 and 62 years with and without HRT. The improvement in sexual pain, vaginal lubrication and orgasm with HRT was found to be statistically significant. No improvement was found in the area of sexual arousal or desire, findings that are consistent with the evidence that these areas are more influenced by relationship and personal factors, or by androgen levels, than by estrogen status.
Androgen deficiency & androgen therapy
Despite the lack of clarity surrounding the role of androgens in the female sexual response, many pharmaceutical products have been extensively investigated for their efficacy in correcting androgen deficiencies in the hope that they may provide the key to treating female sexual problems. The use of androgens remains highly contentious since debate rages over its efficacy and safety.
Androgen therapy is often considered for the treatment of HSDD, particularly afer oophorectomy (where there is a sudden decrease in serum androgens) and in postmenopausal women, and is available as subcutaneous pellets, low-dose androgen gel (off licence) or as a testosterone patch, usually combined with systemic or topical estrogens. The use of the testosterone patch in naturally and surgically menopausal women has been extensively evaluated in a number of studies [47–49], but the subject remains controversial.
Davis et al. conducted a randomized, controlled trial in order to examine the safety and efficacy of a testosterone patch in a group of 61 surgically menopausal women who were receiving concomitant oral estrogen therapy. Women receiving the testosterone patch had significantly increased scores in the domain of sexual desire compared with the placebo group at the end of this 24-week trial. Testosterone-treated women also experienced increased scores in the domains of arousal, orgasm, decreased sexual distress, increased responsiveness and improved self image [47].
Summary of factors relating to menopause and middle age that may impact on female quality of sexual life
Vasomotor symptoms
Urogenital atrophy and dryness
Depression and mood changes
Fatigue
Sleep disturbance
Somatic aches and pains
Personal and cultural attitudes to menopause and aging
Personal and cultural attitudes to sex
Acceptance of role change in life
Body image and self esteem
Life stresses
Loss or change of partner
Feelings and attitudes towards a partner and the relationship
Partner's feelings and attitudes to the woman and the relationship
Partner's sexual problems
The authors of this study concluded that the testosterone patch demonstrated efficacy and safety in the treatment of HSDD; however, this conclusion has since been widely debated and criticized, with opponents arguing that, despite the statistically significant results, the clinical significance of the treatment is in fact marginal; the testosterone group only gained one more satisfactory sexual experience per month than the placebo group, which opponents argued, was not worth the potentially increased risk of side effects [50]. The lack of data relating to the longer-term side effects of the intervention was also criticized.
Most studies investigating short-term androgen therapy appear to demonstrate that use is well tolerated [47,48]; however, the possible side effects of androgen use include hirsutism, acne and other signs of virilization, polycythaemia, increased high-density lipoproteins, cardiovascular risk and possible endometrial hyperplasia in women without hysterectomy [46]. There is little evidence for the safety of long-term androgen therapy in women.
The testosterone patch has been recently approved for short-term use in surgically menopausal and postmenopausal women experiencing HSDD by the European Medicines Agency. It is not approved by the US FDA owing to concerns over its long-term safety.
Psychological interventions
This review has already established that women's quality of sexual life at menopause is determined by a complex interplay of multiple factors with psychological and psychosocial factors appearing to be greater predictors of quality of sexual life than physical factors, such as the presence of menopausal symptoms or problems of sexual function. Thus, interventions that address psychological and psychosocial factors could be interpreted as being of greater benefit to women with poor quality of sexual life than the pharmaceutical interventions that address physical symptoms and problems of sexual function. The efficacy of psychological interventions is difficult to establish from the current literature, probably owing to the variables involved in psychological interventions (e.g., type of psychological intervention as well as therapist and participant characteristics) do not lend themselves easily to comparative studies.
Interventions aimed at treating sexual problems caused by psychological and psychosocial factors may include psychodynamic psychotherapy (based on Freudian theories), individual counseling and cognitive therapies (e.g., cognitive analytic therapy) and sex therapy [46]. Each of these interventions focuses on the individual (i.e., the female patient) and may therefore be useful when the barrier to sexual wellbeing comes from the patient herself; for example, when the root of the poor quality of sexual life is the patient's attitude towards sex, aging or menopause, difficulty adjusting to the new sexual role or role in life, or current life stresses. Where the barrier to quality of sexual life lies within the woman's relationship with her sexual partner, couple therapy can be offered.
Conclusion
Contrary to popular expectation, there is a substantial prevalence of sexual activity among middle-aged women, and the majority of middle-aged women express satisfaction with the quality of their sexual lives. At first, prevalence data for sexual problems in menopausal women appear to suggest that a good quality of sexual life is not the experience of the majority of women in menopause and beyond, with estimates of the prevalence of female sexual problems variously reported to lie within 33–51% of the sexually active middle-aged population, until it is revealed that the prevalence of sexual problems across all ages, including younger and premenopausal women, falls within a similar range of 20–50%.
The true prevalence of sexual dysfunctions in menopausal women is controversial and remains to be determined. Difficulties in assessing the true prevalence of FSDs appear to stem from inconsistent use of the definitions of FSDs, the use of different and occasionally unvalidated instruments to assess sexual problems, differing study populations and the methodological difficulties of distinguishing the effects of menopause from the effects of aging. Studies using the updated DSM-IV classification (with the inclusion of ‘marked distress and interpersonal difficulty’ required for the diagnosis of FSD) are demonstrated to produce lower estimates of the prevalence of overall and specific sexual problems. Identification of the true prevalence of FSD in menopausal women is important since overestimates exaggerating the extent to which women suffer from FSDs may medicalize what is in fact a normal consequence of menopause and aging, causing distress to the population, who may begin to perceive their own experience of sexual issues with aging as being in some way dysfunctional.
There is evidence to suggest that although the prevalence of problems with sexual function does appear to increase with age, rates of FSD remain essentially constant owing to decreasing levels of distress within this area of women's lives as they age. This cautions the practitioner against equating the presence of a problem of sexual function with a poor perceived quality of sexual life.
The most prevalent FSDs demonstrated to be linked to menopause include lack of desire and low libido, reduced sexual arousal and dyspareunia. These can, for the most part, be explained by the hormonal physiological changes that are associated with menopause, particularly by the decline in serum estrogens. The precise role of androgen depletion on the sexual response is less clear.
Symptoms conclusively linked to menopause status (e.g., vasomotor and urogenital symptoms) have the theoretical potential to disrupt women's overall and quality of sexual life; however, studies demonstrate that overall quality of life is not compromised by menopausal symptoms and that stress, relationship status and attitude towards aging have a far greater impact on middle-aged women's overall quality of life. Although mood changes are frequently associated with menopause in the professional and lay literature, there is no conclusive link between menopause status and depression. Factors predictive of depression in middle age include prior depression, poor health, current life stressors and poor partner relationships.
Executive summary
There is increasing medical interest in the sexuality of menopausal and older women.
A substantial proportion (75%) of the female population is sexually active around the age of menopause and into the years beyond.
Sexual wellbeing is a legitimate topic for healthcare practitioners to broach with menopausal and older female patients.
Quality of sexual life is not synonymous with the presence or absence of sexual problems, but encompasses the extent to which patients are ‘bothered’ by their problems, their satisfaction with their sexual lives and their sexual wellbeing. It is inherently subjective.
The majority of studies investigating the effects of menopause focus either on overall quality of life or its impact on sexual function and do not distinguish between sexual function and quality of sexual life.
Menopause is defined as the permanent cessation of menstruation resulting from loss of ovarian follicular activity. It is a retrospective diagnosis based on 12 months of amenorrhea from the woman's last menstrual period, occurring at an average age of 51.3 years. Menopause may be induced at an earlier age by oophorectomy, for which the transition is abrupt.
Of the substantial proportion of middle-aged and older women who are sexually active, the majority are satisfied with their sex lives.
The prevalence of sexual activity declines with age, as does the importance placed on sexual activity.
The most common reasons for decreased sexual activity in the older age group include partner or own health problems, or female lack of interest. Whether these factors are significant in menopausal women cannot be established from the available literature.
The definition and true prevalence of female sexual dysfunctions (FSDs) is controversial. Variation in prevalence data arises from the differing study designs, populations investigated, instruments used and whether the Diagnostic and Statistical Manual of Mental Disorders IV inclusion of ‘personal distres’ is adopted by the study. Including personal distress in the study method yields lower prevalence rates.
The prevalence of female sexual problems across all ages is reported to be between 20 and 50%. In middle-aged and older women it is reported to be between 33 and 51%. The overall prevalence of FSD appears to remain fairly constant with increasing age. This is attributed to reduced levels of distress associated with poor sexual function as age increases.
The reported prevalence of specific FSDs in middle-aged and older women also shows considerable variation. Specific FSDs associated with increasing age and menopause status are: sexual desire/interest disorders, sexual arousal disorders and dyspareunia.
The hormonal outcome of menopause is an increase in serum levels of follicle-stimulating hormone and a decrease in estradiol, inhibin (A and B) and sex hormone-binding globulin. Levels of dihydroepiandrosterone sulphate decrease with increasing age but are not associated with menopause status. Total testosterone decreases with increasing age throughout women's reproductive lives. Bilateral oophrectomy induces a sharp decline in estradiol and total testosterone.
Vasomotor symptoms and urogenital symptoms are recognized to be conclusively linked to menopause status. Despite popular assumption, cognitive and mood disturbances are not linked to menopause status. Menopausal symptoms do not appear to impact on overall quality of life in middle-aged women. The main factors affecting overall quality of life are socioeconomic factors, daily stresses and marital status.
The majority of middle-aged women in Western society have a positive attitude to menopause and aging and associate it with an increased sense of freedom. This positive attitude to menopause contributes positively to women's quality of sexual life.
Relationship factors are demonstrated to have an impact on menopausal women's perceived quality of sexual life that exceeds the effects of menopause status and symptoms.
Pharmaceutical interventions include estrogen therapies, which improve problems of sexual pain, vaginal lubrication and orgasm, and androgen therapy, which may be used to treat hypoactive sexual desire disorder in surgically menopausal women. The use of the testosterone patch is controversial owing to disputed evidence of its clinical efficacy and concerns regarding its long-term use.
Psychological interventions address the psychological and psychosocial (including relationship) factors that affect women at midlife and impair quality of sexual life.
An holistic treatment approach, integrating pharmaceutical and psychological interventions, may be more appropriate in the management of problems of quality of sexual life in menopause than separate interventions, reflecting the complex interplay between the many factors that may impact on quality of sexual life in menopause.
Healthcare practitioners will encounter a greater demand for interventions that address menopausal women's sexual wellbeing in the future.
Continued research will increase the understanding of the female response, leading to improved pharmaceutical and psychological interventions and integration of therapeutic modalities.
Greater cohesion of definitions, methods and measurements is required in order to increase understanding of the impact of menopause on sexual life.
Psychological and psychosocial changes occurring at midlife, such as personal and cultural attitudes towards the menopause and sex, changes in perceived role in life and relationship factors significantly impact on women's perceived quality of sexual life, to a far greater extent than the physical changes brought about by menopause. The positive attitude that the end of menstruation heralds freedom from pregnancy and childcare, and the subsequent freedom for women to concentrate on their own needs is demonstrated to improve the quality of sexual life. Changes to partner relationships, such as the loss or gain of a sexual partner or a change in the partner's own sexual function, impact greatly on women's sexual experience at midlife, bringing about improvements or detrimental change.
The use of estrogen replacement therapy/topical estrogens and androgen therapy represent just two of the many pharmaceutical interventions that are promoted as improving sexual function in women following natural and surgical menopause. Estrogen replacement has been conclusively demonstrated to improve sexual symptoms such as vaginal dryness and the subsequent problem of dyspareunia. The use of androgen therapy for treating the sexual symptoms of lack of desire and low libido is controversial since the mechanism by which androgen deficiency impacts on sexual function has not been clarified and because the data on the efficacy and safety of the testosterone patch are argued to be limited. Psychological interventions are also employed to treat the psychological and psychosocial changes that may affect women or their partners around midlife. The efficacy of these interventions is inherently difficult to measure.
The complexities of the factors that influence menopausal women's quality of sexual life, whether physical, psychological or psychosocial, have been demonstrated in this review. In addition to this, physical problems of sexuality rarely occur in isolation from psychological/psychosocial problems and vice versa. Thus, it would seem appropriate to address the management of problems with menopausal women's quality of sexual life in a holistic manner, employing both types of intervention in an integrated approach. Currently, pharmaceutical interventions aimed at treating the sexual problems attributed to hormonal imbalances enjoy a much higher profile in the treatment of female sexual problems compared with psychological interventions, despite the evidence, as presented in this review, that indicates psychological factors have a greater impact on the quality of sexual life in menopause.
Future perspective
It seems inevitable that the development of new pharmaceutical therapeutics will drive increased public awareness of FSD during and after menopause, if the increased awareness of male sexual dysfunction following the development and marketing of drugs, such as Viagra, is to be taken as precedent. This suggests that healthcare practitioners will encounter a greater demand for interventions that address menopausal women's sexual wellbeing in the future as public awareness increases. It is likely that continued research in this area will improve understanding of the female sexual response, leading to improvements in both pharmaceutical and psychological interventions, and a better understanding of which circumstances each of these would be most appropriately applied.
As discussed in this review, the clinical definition FSD does not necessarily equate to poor quality of sexual life, which much be assessed from an individual's perspective. Future studies should take cognizance of this when assessing quality of sexual life during menopause and developing appropriate interventions. There should be greater cohesion between the definitions, methods and measurements employed in assessing the impact of menopause on quality of sexual life, and increased differentiation between changes occurring due to menopause, as opposed to changes with respect to age. It is expected that given the increasing interest in the field, such developments will be implemented over the next few years.
Footnotes
Wylie has received consulting fees, been a symposium speaker and/or advisory board member for several companies in women's sexual health, including Procter & Gamble, Boehringer Ingelheim, Durex, and Johnson & Johnson. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.
No writing assistance was utilized in the production of this manuscript.