Misconceptions About Sexual Health in Older Women

Abstract

Sexual satisfaction has been linked to quality of life throughout a person’s life, and distress related to sexual dysfunction impacts the health of the individual and their relationship.1Lindau S.T. Stumm L.P. Lauman E.O. Levinson W. O’Muircheataigh C.A. Waite L.J. A study of sexuality and health among older adults in the United States.N Engl J Med. 2007; 357: 762-774Crossref PubMed Scopus (1374) Google Scholar A common misconception is that aging women are not sexually active. National representative data indicate that, while sexual activity declines with age, both men and women continue to engage in in vaginal intercourse, oral sex, and masturbation even in the eighth and ninth decades of life.1Lindau S.T. Stumm L.P. Lauman E.O. Levinson W. O’Muircheataigh C.A. Waite L.J. A study of sexuality and health among older adults in the United States.N Engl J Med. 2007; 357: 762-774Crossref PubMed Scopus (1374) Google Scholar However, patients and medical providers lack understanding about female sexual function, particularly in older women. To offer appropriate management to patients, the effects of age-related changes in sexual function must be distinguished from the effects of health changes on sexual function. Sexual function in women is multifaceted and is affected by somatic, psychosocial, and neurobiological factors.2Kingsberg S.A. Clayton A.H. Pfaus J.G. The female sexual response: current models, neurobiological underpinnings and agents currently approved or under investigation for the treatment of hypoactive sexual desire disorder.CNS Drugs. 2015; 29: 915-933Crossref PubMed Scopus (59) Google Scholar Sexual dysfunction is assessed in the domains of desire, arousal, orgasm, and pain. Sexual desire or libido is complex and is influenced by various factors, including the physical and psychological health of the patient, relationship concerns, past sexual experiences, and personal beliefs about sexual activity. Arousal is a neurovascular response to desire that is characterized by vascular congestion in the breasts, clitoris, and vagina (resulting in vaginal lubrication). Orgasm, which may follow arousal, is marked by sexual release followed by rhythmic contractions in the pelvic musculature. Pain related to penetrative sexual activity may occur with initial or deep penetration (or both).2Kingsberg S.A. Clayton A.H. Pfaus J.G. The female sexual response: current models, neurobiological underpinnings and agents currently approved or under investigation for the treatment of hypoactive sexual desire disorder.CNS Drugs. 2015; 29: 915-933Crossref PubMed Scopus (59) Google Scholar The timing of the pain is an important distinction for identifying the underlying cause of the pain.3Faubion S.S. Rullo J.E. Sexual dysfunction in women: a practical approach.American Fam Phys. 2015; 92: 281-288PubMed Google Scholar The normal aging process, even in healthy women, generally leads to an increased prevalence of sexual complaints. Difficulties may occur in one or more domains of sexual function, most commonly, desire for sexual activities. However, these complaints may or may not be associated with distress. Decreased estrogen levels after menopause lead to the genitourinary syndrome of menopause (GSM), previously known as vulvovaginal atrophy. Genitourinary syndrome of menopause, which occurs in approximately 50% of postmenopausal women, is characterized by an alteration in the vaginal microbiome and architecture of the vagina and vulva; the result is vaginal dryness and pain with penetration.4Kingsberg S.A. Wysocki S. Magnus L. Krychman M.L. Vulvar and vaginal atrophy in postmenopausal women: findings from the REVIVE (Real Women’s Views of Treatment Options for Menopausal Vaginal Changes) survey.J Sex Med. 2013; 10: 1790-1799Abstract Full Text Full Text PDF PubMed Scopus (264) Google Scholar Age-related decrease in genital blood flow and diminished genital sensation, along with decreased pelvic floor tone may contribute to a delayed or a less intense orgasm. Decreasing levels of estrogen and androgens may also contribute to low desire, difficulty with arousal, and impaired orgasm.5Davis S.R. Davison S.L. Donath S. Bell R.J. Circulating androgen levels and self-reported sexual function in women.JAMA. 2005; 294: 91-96Crossref PubMed Scopus (394) Google Scholar Distress related to sexual function is the hallmark of female sexual dysfunction. In the Prevalence of Female Sexual Problems Associated With Distress and Determinants of Treatment Seeking (PRESIDE) study of 31,000 women aged 18 to 102 years, sexual health concerns increased with age; sexual complaints were reported by 27% of women aged 18 to 44 years, by 44.6% aged 45 to 64 years, and by 80.1% aged 65 years or older. Interestingly, distress related to sexual problems was the highest (14.8%) in the middle-age group (45 to 64 years old) and the lowest (8.9%) in women 65 years or older.6Shifren J.L. Monz B.U. Russo P.A. Segreti A. Johannes C.B. Sexual problems and distress in United States women: prevalence and correlates.Obstet Gynecol. 2008; 112: 970-978Crossref PubMed Scopus (824) Google Scholar In addition to the changes that accompany normal aging, chronic medical conditions and related treatment in older women may have a profound effect on sexual function (Table). An important consideration not to be overlooked and commonly reported in partnered women is the lack of sexual activity due the partner’s health.1Lindau S.T. Stumm L.P. Lauman E.O. Levinson W. O’Muircheataigh C.A. Waite L.J. A study of sexuality and health among older adults in the United States.N Engl J Med. 2007; 357: 762-774Crossref PubMed Scopus (1374) Google Scholar In general, women who rate their health as poor are less likely to be sexually active, and women with poor health who do remain sexually active often report sexual problems.1Lindau S.T. Stumm L.P. Lauman E.O. Levinson W. O’Muircheataigh C.A. Waite L.J. A study of sexuality and health among older adults in the United States.N Engl J Med. 2007; 357: 762-774Crossref PubMed Scopus (1374) Google ScholarTableChronic Medical Conditions and Related Treatment in Older Women That May Have a Profound Effect on Sexual FunctionaGSM = genitourinary syndrome of menopause.,bData from Kingsberg et al.3ConditionPhysiologic affectSexual function impactedDiabetes mellitusDiminished genital vascular supplyDeceased arousal and orgasmCardiovascular diseaseDiminished genital vascular supplyDecreased arousal and orgasmPeripheral neuropathyImpact on small nerve fibers in vulva and anterior vaginaDecreased genital sensation and impaired arousalNeuromuscular disorders/spinal cord/multiple sclerosisDirect effect on vulvar/vaginal innervationAssociated painDecreased desire and arousalMalignancyDirect effect of diagnosis and treatment-Menopausal hormone lossGSMVaginal stenosis/dyspareuniaDecreased desire, genital sensation, arousal, and orgasmMusculoskeletal conditionsDifficulty with movement/positioningDeceased desire and arousalGynecologic conditionsPelvic organ prolapseUrinary incontinenceSurgical interventions: hysterectomy/oophorectomyDyspareuniaLoss of urine during intercourseLoss of systemic estrogenDeceased desire and genital sensation, arousal and orgasma GSM = genitourinary syndrome of menopause.b Data from Kingsberg et al.3Faubion S.S. Rullo J.E. Sexual dysfunction in women: a practical approach.American Fam Phys. 2015; 92: 281-288PubMed Google Scholar Open table in a new tab Additionally, medications can cause or worsen pre-existent sexual health problems. Selective serotonin reuptake inhibitors induce sexual dysfunction in 30% to 70% of women and lead to complaints in the domains of sexual desire, arousal, and orgasm.3Faubion S.S. Rullo J.E. Sexual dysfunction in women: a practical approach.American Fam Phys. 2015; 92: 281-288PubMed Google ScholarAntihistamine and anticholinergic medications may impede arousal, and common cardiovascular drugs (eg, β-blockers) may negatively affect sexual desire.3Faubion S.S. Rullo J.E. Sexual dysfunction in women: a practical approach.American Fam Phys. 2015; 92: 281-288PubMed Google Scholar While moderate alcohol consumption has been associated with perceived improvement in sexual function, alcohol intoxication impairs sexual response.7George W.H. David K.C. Heiman J.R. Women’s sexual arousal: effects of high alcohol dosages and self-control instructions.Horm Behav. 2011; 59: 730-738Crossref PubMed Scopus (22) Google Scholar There are both provider and patient barriers to discussing sexual health–related matters in aging women. This is sometimes due to a discrepancy between patient and provider in age and sex (when the provider is male).1Lindau S.T. Stumm L.P. Lauman E.O. Levinson W. O’Muircheataigh C.A. Waite L.J. A study of sexuality and health among older adults in the United States.N Engl J Med. 2007; 357: 762-774Crossref PubMed Scopus (1374) Google Scholar Moreover, providers often perceive sexual health matters as being private and consider related discussions to be offensive and a breach of the patient’s privacy.1Lindau S.T. Stumm L.P. Lauman E.O. Levinson W. O’Muircheataigh C.A. Waite L.J. A study of sexuality and health among older adults in the United States.N Engl J Med. 2007; 357: 762-774Crossref PubMed Scopus (1374) Google Scholar The lack of medical training on age-related changes in female sexuality contributes to providers being less confident in dealing with sexual health.8Gott M. Hinchliff S. Galena E. General practitioner attitudes to discussing sexual health issues with older people.Social Sci Med. 2004; 58: 2093-2103Crossref PubMed Scopus (254) Google Scholar A summit on medical school education in sexual health reported the lack of a well-developed and consistent curriculum relating to sexual medicine in the United States and Canada.9Coleman E. Joycelyn Elders J. David Satcher D. et al.Summit on medical school education in sexual health: report of an expert consultation.J Sex Med. 2013; 10: 924-938Abstract Full Text Full Text PDF PubMed Scopus (91) Google Scholar Patients are also often reluctant to discuss sexual health concerns with their primary care providers; in a survey of older adults across the United States, 96% of women and 92% of men who had at least one sexual problem had not sought help.1Lindau S.T. Stumm L.P. Lauman E.O. Levinson W. O’Muircheataigh C.A. Waite L.J. A study of sexuality and health among older adults in the United States.N Engl J Med. 2007; 357: 762-774Crossref PubMed Scopus (1374) Google Scholar How can providers of any medical specialty approach a conversation regarding sexual concerns in older women? As in the PLISSIT model, normalizing and giving the patient permission (P) to discuss sexual concerns is primary. The patient can be counseled according to their health status, as opposed to age, giving limited information (LI) on how their medical condition may affect their sexual health. Specific suggestions (SS) to improve identified issues can be discussed and referral for intensive therapy (IT) if warranted.10Annon J.S. The PLISSIT model: a proposed conceptual scheme for the behavioral treatment of sexual problems.J Sex Educ Ther. 1976; 2: 1-15Crossref Scopus (331) Google Scholar In addition, a validated single-item questionnaire offered as part of medical history can provide opportunity for open discussion.11Flynn K.E. Lindau S.T. Lin L. et al.Development and validation of a single-item screener for self- reporting sexual problems in US adults.J Gen Intern Med. 2015; 30: 1468-1475Crossref PubMed Scopus (35) Google Scholar Treatment options are directed at the specific concerns and underlying conditions. Dyspareunia and vaginal dryness are a common problem often occurring simultaneously in 80% of postmenopausal women.12Archer D.F. Labrie F. Montesino M. Martel C. Comparison of intravaginal 6.5 mg (0.50%) prasterone, 0.3 mg conjugated estrogens and 10 μg estradiol on symptoms of vulvovaginal atrophy.J Steroid Biochem Mol Biol. 2017; 174: 1-8Crossref PubMed Scopus (25) Google Scholar For mild symptoms, vaginal lubricants and moisturizers may suffice. For moderate to severe symptoms in appropriately selected patients, hormonal treatments may include vaginal estrogen or dehydroepiandrosterone (DHEA) and oral ospemifene.13Faubion S.S. Kingsberg A. Shifren J.L. et al.The 2020 genitourinary syndrome of menopause position statement of the North American Menopause Society.Menopause. 2020; 27: 976-992Crossref PubMed Scopus (65) Google Scholar In comparative studies, both intravaginal estrogen twice weekly and DHEA (6.25 mg) suppository nightly improved vaginal dryness and dyspareunia. However, after 1 year of use, DHEA improved all domains of female sexual dysfunction including desire and orgasm with no increase in sex steroid levels.12Archer D.F. Labrie F. Montesino M. Martel C. Comparison of intravaginal 6.5 mg (0.50%) prasterone, 0.3 mg conjugated estrogens and 10 μg estradiol on symptoms of vulvovaginal atrophy.J Steroid Biochem Mol Biol. 2017; 174: 1-8Crossref PubMed Scopus (25) Google Scholar A recent position statement from the North American Menopause Society outlines safety issues related to topical hormone treatment of GSM.13Faubion S.S. Kingsberg A. Shifren J.L. et al.The 2020 genitourinary syndrome of menopause position statement of the North American Menopause Society.Menopause. 2020; 27: 976-992Crossref PubMed Scopus (65) Google Scholar Currently, no US Food and Drug Administration–approved medications are available to enhance female sexual function (desire, arousal, or orgasm) in postmenopausal women. While flibanserin has been found to improve hypoactive sexual desire disorder in postmenopausal women, it is US Food and Drug Administration–approved for this indication in premenopausal women only.14Simon J.A. Davis S.R. Altof S.E. et al.Sexual well-being after menopause: an International Menopause Society white paper.Climacteric. 2018; 21: 415-427Crossref PubMed Scopus (39) Google Scholar Herbal medications designed to enhance libido have not been studied in the elderly.15Lester P.E. Kohen I. Stefanacci G. Feurerman M. Sex in nursing homes: a survey of nursing home policies governing resident sexual activity.J Am Med Dir Assoc. 2016; 17: 71-74Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar The use of a personal vibrator or pillows for positioning during sexual activity may enhance sexual function. Patients with more complex sexual health issues may need a multidisciplinary approach including psychotherapy or sex therapy.3Faubion S.S. Rullo J.E. Sexual dysfunction in women: a practical approach.American Fam Phys. 2015; 92: 281-288PubMed Google Scholar Social determinants of sexual function are equally important. Women residing in an assisted-living facility or a nursing home may still need tenderness, sexual contact, and emotional closeness, but the lack of privacy, attitudes of staff and family members, lack of a sexual partner, and physical limitations are some of the identified barriers to healthy sexual expression in institutional care.15Lester P.E. Kohen I. Stefanacci G. Feurerman M. Sex in nursing homes: a survey of nursing home policies governing resident sexual activity.J Am Med Dir Assoc. 2016; 17: 71-74Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar Furthermore, facilities may have policies that inhibit sexual activity out of concern for resident safety. Sometimes sexual activity requires the approval from a resident’s representative (eg, a family member).15Lester P.E. Kohen I. Stefanacci G. Feurerman M. Sex in nursing homes: a survey of nursing home policies governing resident sexual activity.J Am Med Dir Assoc. 2016; 17: 71-74Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar Certainly, patient safety concerns are appropriate if the patient has a cognitive disorder. Proactive policies that balance the autonomy of residents with their safety are likely to enhance the quality of life and sense of dignity of residents in long-term care. It is estimated that 20% of the US population will be older than 65 years by 2030. Therefore, the medical community will witness an increasing number of geriatric health issues. Many older women are single, widowed, or have partners with sexual health issues. An often overlooked trend is the increasing rate of sexually transmitted infections, including AIDS, in persons older than 50 years.8Gott M. Hinchliff S. Galena E. General practitioner attitudes to discussing sexual health issues with older people.Social Sci Med. 2004; 58: 2093-2103Crossref PubMed Scopus (254) Google Scholar Moreover, this age group is becoming more socially diverse, with 4% (3 million) projected to be lesbian, gay, bisexual, transgender, or queer.8Gott M. Hinchliff S. Galena E. General practitioner attitudes to discussing sexual health issues with older people.Social Sci Med. 2004; 58: 2093-2103Crossref PubMed Scopus (254) Google Scholar In addition, growing racial diversity calls for health care providers to have culture-specific knowledge and skills. Female sexual function education should be incorporated into medical school curricula to enhance the skills and comfort level of providers in discussing sexual health with patients. With this commentary, our goal is to both challenge and encourage the providers to consider sexual health as an important aspect of women’s health in their midlife years and beyond.

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