First Consensus Meeting on Menopause in the East Asian Region

Sexuality and the menopause

Tay Boon Lin
Division of Obstetrics and Gynaecology, KK Women’s and Children’s Hospital, Singapore

Sexuality exists in one form or another throughout life. It begins with birth and ends with death. Sexual feelings, desires and activities are present throughout the life cycle. Sexuality is a natural and healthy part of living.

Sexuality is not defined by one’s genital behaviour or interests. Rather, sexuality encompasses the sexual knowledge, beliefs, attitudes, values and behaviour of individuals. It also involves an individual’s perception of the qualities that are characteristic of maleness and femaleness [1].

Until recently, attention has focused almost exclusively on the negative aspects of ageing. People are now living longer and are healthier and better educated. This has resulted not only in a substantial growth in the elderly population, but also in an increasing emphasis on the normal aspects of ageing, including issues relating to changing sexuality and overall quality of life. Undoubtedly, sex and sexuality are pleasurable, rewarding and fulfilling experiences that can enhance the later years. They are also enormously complex.

Studies of menopausal sexuality have been difficult because of the physiological changes associated with the ageing process and illnesses which are more common at this time of life. What is established is that the pattern of sexual life before the menopause and the quality of marriage (the relationship status) are important correlates of sexual activity and sexual satisfaction. Nevertheless, the abrupt gonadal hormone decline associated with the menopause does adversely affect sexual function, regardless of the age at which the menopause occurs.

Sexual dysfunction relating to ovarian hormone decline can have direct or indirect effects. The direct effects are the results of genital atrophy which may lead to dyspareunia, vaginismus, inadequate lubrication and loss of libido. The indirect effects result from changes of body contour during ageing, resulting in a perceived loss of sexual attractiveness and a poorer self-image. Some of these changes include weight gain or obesity, and a generalized decrease in tone, strength and elasticity of tissues. This results in sagging, wrinkling and drying out of the skin [2].

Apparently, physical changes are the least of the concerns of ageing women. Problems surrounding intimacy are their primary concern, unlike the male who tends to be preoccupied with the physical aspects. Sexuality in the ageing female is not only influenced by physical changes, but also by psychological, emotional and sociocultural factors and how these factors interact to affect the woman’s total perception of herself.

Physiological changes

As previously stated, hormonal and ageing processes affect sexuality. Ovarian hormonal decline at the menopause has direct effects on the external and internal genital organs, most of the changes being the result of a decrease in pelvic blood flow. Pubic hair decreases, the labia majora atrophy, and the labia minora and clitoris shrink in size. The vaginal changes are often more marked than the external genital changes. The vagina loses glycogen, resulting in a decreased population of lactobacilli, a reduced release of lactic acid and a physiological rise in vaginal pH from 3.5–4.5 to above 5. This increases the risk of vaginal infection. The vaginal epithelium also thins, becoming friable, and may easily bleed. The muscular layers may be replaced by fibrous tissue resulting in a loss of elasticity. With all these changes, the vagina becomes vulnerable to mechanical injury, pale, shorter in length and narrower in diameter, and loses its rugosity. The thinning of the vaginal epithelium, the vaginal dryness and loss of elasticity lead to dyspareunia, postcoital bleeding and pain, and vaginismus can eventually result.

In keeping with the ‘use it or lose it’ admonition, age-related genital changes (e.g. decreased lubrication, inelastic and thin vaginal tissues) are less pronounced in women who are sexually active.

The internal genitalia also shrink to prepubertal size and the endometrial lining atrophies. The atrophy of the urethra and the bladder trigone parallels that of the vagina since both tissues have a common embryonic origin. Because of these changes, women will often complain of severe dysuria, haematuria, urgency, frequency, and recurrent cystitis after coital activity.

Many of these changes are associated with sexual arousal, either directly or indirectly. The usual sexual responses need a longer time, and the overall intensity of sexual experience may be diminished and resolve more rapidly than previously.

All of these changes in the woman’s physiology and patterns of arousal are closely interrelated and affected by similar ageing processes in the male. As in the female, males also require substantially longer periods of time and greater amounts of genital stimulation to achieve erection, with decreased intensity of ejaculation and an increased ejaculation refractory period [3].

Psychological factors

When it comes to sexual issues, it is just as important to address the older woman’s psychological state because that is what defines her sexuality. Women who perceive ageing and the changing life roles at this time of life as negative have greater difficulties with emotional problems. For many of these women, the traditional view of older age as impotent, uninterested in sexuality and sexually non-functional becomes a self-fulfilling prophecy. In the same way, positive attitudes can have a beneficial effect on performance and sexuality. Women who look forward to menopause for its freedom from pregnancy and child-rearing and work responsibilities generally report an increase in sexual feelings and heightened sexuality.

Another important psychological factor in older women is the occurrence of emotional distress related to this time of tumultuous change. Such distress includes increased anxiety, nervousness, irritability, depression and emotional lability. The role of oestrogen in the aetiology of such symptoms is not totally defined. Several studies report little difference in overall psychological and psychosomatic symptoms in women at the menopausal age versus other ages. Nevertheless, adverse life events such as the death of loved ones, children leaving home and the increased probability of serious physical illness which are far more likely to occur at this time may result in some of these symptoms being more common with the menopause.

Sociocultural factors

Other factors that influence the experience of sexuality and self-worth in the older woman include societal attitudes, cultural roles and theological beliefs. Western cultures tend to view both menopause and sexuality in the ageing woman negatively. Older women in such cultures become sexually retired and gender neutral. However, women in cultures that view ageing and menopause more positively have fewer difficulties coping with changing sexuality and easier adjustment to life changes.

Interview surveys in Hong Kong showed that the women there did not generally perceive the menopause negatively, but as a natural phenomenon; while in the Muslim culture of Pakistan the menopause was viewed positively and described as a happy event [4].

Similarly, a symptom profile study of 420 women in Singapore revealed that the incidences of some menopausal complaints were markedly lower when compared with those in European studies and that menopausal symptoms had less impact on women’s lives there than in the West [5].

Singaporean women tend to be more open about their sexual problems than their neighbours. There are no hard data, but anecdotally, Singaporean women’s main sexual problem 3–5 years before the menopause is vaginal dryness. This may be due to ageing or stress which slows down the sexual arousal and response times.

The main reason for declining sexuality in older women is the unavailability of a healthy and willing partner. Given the availability of a partner, the same general high or low rate of sexual activity can be maintained throughout life. However, sexual desire remains intact. In fact, there is an age-related trend towards using quality of sexual experience over quantity as a measure of life satisfaction. The need for closeness, caring and companionship is life-long [3].

Finally, religious issues may sometimes play a role. Many traditional religions minimize the role of sexuality and limit sexual intercourse only for procreation. With the definitive end of fertility at the time of the menopause, this gives the impression that sexuality and sexual intercourse are less important with ageing. However, sexual activity/expression should always be part of a loving relationship between men and women.

Hormone replacement therapy

Hormone replacement therapy (HRT), besides controlling vasomotor symptoms and preventing osteoporosis and cardiovascular disease, is also important in the treatment of menopausal sexual dysfunction. Oestrogen replacement therapy has a beneficial effect on urogenital tissue, and by indirectly alleviating vasomotor symptoms and improving sleep, mood is also enhanced. If there is no improvement after HRT, other causes should be evaluated and sexual counselling offered.

The addition of androgens to HRT should be considered when a patient continues to complain of loss of sexual desire in the absence of other factors contributing to this complaint. Androgens have been shown to increase sexual desire, increase sexual fantasy and maintain libido [6].

Sex and illness

Besides lack of a partner, illness also steals the sex lives of many of the elderly. Sexual activity may be limited by specific disabilities, but sexuality and the expression of love and caring do not have the same limitations. Rather than focusing on the losses associated with illness, more attention should be paid to what is possible. The psychosexual impact of disability generally has a greater effect on sexuality than the physical limitations of the disability itself. An emphasis on confidence-building and new forms of sexual expression can be a great help to people suffering from debilitating illnesses.

Conclusion

Sexuality is not just genital stimulation. It encompasses the entire realm of human contact and communication and it is the way people define and present themselves.

Sexuality in the elderly woman is a complex phenomenon affected by the interaction of physical, psychological and sociocultural factors. Although frequently underestimated, sexuality remains extremely important throughout the life cycle and has important implications for enhancing self-esteem, a positive self-image and overall quality of life.

References

1. Barber HRK. Perimenopausal and geriatric gynecology. New York: Macmillan; 1988.

2. Leiblum S, Bachmann G. The sexuality of the climacteric woman. In: Eskin B, ed. The menopause. Comprehensive management. New York: Macmillan, 1988; 165–80.

3. Byyny RL, Speroff L. A clinical guide for the care of older women. Baltimore, MD: Williams & Wilkins; 1990.

4. Berg G, Hammar M, ed. The modern management of the menopause. New York: Parthenon, 1993; 35–55.

5. McCarthy T. The prevalence of symptoms in menopausal women in the Far East: Singapore segment. Maturitas 1994: 19/3: 199–204.

6. Sherwin BB, Gelfand MM, Brender W. Androgen enhances sexual motivation in females: a prospective crossover study of sex steroid administration in the surgical menopause. Psychosom Med 1985; 47: 339–51.