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From our collaborators at Johns Hopkins Medicine | Sexual health in older women

Current research on sexual activity, satisfaction, and dysfunction in women as they age

Two people in lying in bed together

We all expect our bodies to change as we age, but most people know little about what to expect from sex as we age. In Western cultures, older adults often are portrayed as either uninterested in or incapable of sexual activity, the so-called “asexual elderly.” However, several large studies done in the United States and United Kingdom have demonstrated the “asexual elderly” to be more of a myth than a reality.

According to these studies, both men and women value sexual health as they age, and the majority of older adults rate sexual activity as very important in their lives. Further, cross-sectional studies also show that sex correlates to happiness with aging and that being sexually active seems to protect against heart disease, premature death, declines in functioning and memory loss. From this, it is reasonable to conclude that sexual activity is good for you as you age!

Sexual activity does change with aging

As people age, their focus of sex often changes, shifting from a means to achieve orgasm more to seeking pleasure and intimacy. Thus, with aging we need to consider very broadly the definition of what constitutes sexual health. In this article, I’d like to focus on what we know about sexual activity, satisfaction and dysfunction in older women. This discussion includes one very important caveat: There are very few adequately sized studies to evaluate the experiences of ethnic or sexual minorities in relation to sexuality and aging. Thus, the comments here apply to what is known about cis-gendered heterosexual women.

Most women remain sexual active as they age

One large study in the United States of women ages 28 to 84 years known as the Survey of Midlife Development conducted a self-administered questionnaire to gain insight into sexual health and aging. Importantly, this study demonstrated that while the proportion of women who are sexually active decreases with aging, sexual activity was still very common even at advanced ages.

The researchers found that 60 percent of women older than 60 who have a partner reported being sexually active regularly. Indeed, women who were married or co-habitating were about eight times more likely to be sexually active than those who did not have a co-habitating partner or spouse.

Of the sexually active women, 52 percent reported having had sex at least weekly, and almost 85 percent reported having sex at least monthly. Women who were more sexually active related that they had higher relationship satisfaction and better communication with their partners, and they felt that sex was very important to their overall sense of well-being. This study highlights that while losing a partner is a prominent risk factor for dissatisfaction with sexual health with aging, there are certainly additional contributing health concerns.

Hormones, menopause and surgery impact sexual health

The menopause transition represents significant hormonal changes that affect overall feelings of well-being, body image and hormone levels important to sexual health, especially estrogen. This is true in the case of natural menopause (which usually occurs in women in their late 40s to early 50s), or whether it’s sudden and dramatic, as is in the case of surgery to remove the ovaries.

Dramatic decreases in estrogen at the time of menopause contribute to changes in the blood flow to the pelvic area, which often reduces the pelvis’ sensitivity to sexual stimulation, requiring more stimulation to achieve the same level of arousal as before menopause. Decreases in estrogen also contribute to decreases in vaginal lubrication in response to stimulation, and sometimes to thinning of the vaginal wall, which can cause pain or spotty bleeding with intercourse if not addressed sufficiently.

Women’s testosterone levels also may decline after menopause, which can contribute to changes in sexual desire and other aspects of sexual health. However, researchers are still investigating the relationship between testosterone levels and sex. Many women have described that the intensity of their orgasms tends to wane after menopause, but, again, researchers don’t yet fully understand why.

Expert consider all of these changes related to menopause to be normal. However, many women are not informed about how menopause may impact their sexual health and may be relieved to know that the changes they are noticing may, indeed, be a normal part of aging.

Some sex concerns aren’t due to menopause

Many women will have concerns that extend beyond mild changes related to menopause. It is important to understand that concerns about sexual health are common and important to explore. “Female sexual dysfunction” is a general term conveying problems related to sex that are significantly distressing and warrant further evaluation and treatment.

Female sexual dysfunction is usually further divided into more specific areas of concern, including problems with interest, arousal and orgasm, or pelvic pain and penetration disorder. As many as one in eight women in the United States report distressing sexual health concerns relating to at least one of these categories, and up to 40 percent have symptoms of sexual dysfunction but don’t find them very distressing. Most often, these problems relating to sexual dysfunction have several simultaneous contributing factors related to psychology, culture and relationships. A physician can conduct a thorough evaluation to address possible contributing factors.

Common conditions also affect sexual interest as we age

There are many biologic factors that can contribute to decreased sexual health with aging, and the majority can be addressed in a primary care setting. A variety of chronic medical conditions may impact women’s sexual health:

  • Arthritis of the hips or spine can contribute to pain, discomfort and inability to sustain particular positions during sexual activity.
  • Women who have suffered a heart attack often have concerns that stressing their hearts could disrupt their desire and arousal.
  • Diabetes is very common as we age and can impair sexual desire.
  • Gynecologic conditions common with aging can contribute to diminished sexual health, including pelvic organ prolapse and pelvic muscle dysfunction, both of which can cause very painful intercourse.
  • Hypothyroidism can cause problems with lubrication and orgasm.
  • Many malignancies can decrease sexual interest. For example, women who have had mastectomies or other disfiguring cancer surgeries may suffer from impaired body image.
  • Some chemotherapies such as anti-estrogen medications can directly cause a decrease in sexual desire, sexual arousal and orgasm.
  • People with dementia may demonstrate either increased or decreased sexual desire and may have a harder time communicating their wants to partners, or in understanding their partner’s wants.
  • Active depression commonly suppresses sex drive, and medications for depression commonly impair sex function.

Medications matter in sexual health

Medications also can impact sexual function, so if a woman is having difficulty with sex, she should review all of her prescriptions. As they get older, many women control bladder incontinence with anti-cholinergic medications, which can negatively impact sexual health. Many cardiovascular medications can contribute to decreasing sexual desire. As is well-known, antidepressant medications may contribute to difficulty with sexual desire, arousal and orgasm.

Women’s body image can affect sexual interest

Finally, many psychological, social and partner-related factors can contribute to dissatisfaction with sexual health, including depression, anxiety, poor body image, emotional neglect or history of abuse. As noted previously, partner availability and interest in sex are strongly related to women’s sexual activity. Understanding how a woman relates to partners is prudent in considering her sexual health. As women age, their partners are also older and may have some of the same contributing health conditions, consume medications that impact sex or suffer from erectile dysfunction (if male).

You should discuss these issues with your physician

The good news is your physician can help address nearly all these issues so you can improve your sexual health. Usually a physician will obtain a careful sexual history and do a complete physical examination, and most individuals will not need any extensive laboratory testing. When the primary problem is difficulty with sexual interest or arousal, it is important to determine whether this is a longstanding issue or a more recent one, and whether menopause has contributed to decrease in lubrication or genital blood flow, which over-the-counter topical lubricants can remedy.

Pain with conventional penetration is particularly important to address early because women often develop anticipatory pain that can cause anxiety and a marked tightening of the pelvic muscles, which can lead to worsening discomfort and become a vicious cycle. Treating the sexual dysfunctions described above require individualized interventions that depend on the woman’s specific issues.

For example, when medications may be at fault, physicians can reduce doses or prescribe other medications that could markedly improve sexual functioning. Similarly, women can consider alternative activities that still result in pleasure and intimacy when chronic conditions cause sexual dissatisfaction.

When vaginal dryness is the primary concern, topical estrogen or topical lubricants can be incredibly effective. Ospemifene is a selective estrogen receptor modulator that has been shown to improve vaginal dryness in women with moderate to severe pain with vaginal penetration. Women with dysfunctional pelvic floor musculature can benefit from pelvic floor physical therapy. There are ongoing studies evaluating whether testosterone therapy is safe and effective in improving sexual drive and arousal, but this research is not yet conclusive. For more challenging problems, psychologists, sexual counselors or other specializes experts may be able to help.

You can enjoy sex as you age: Talk to your physician

Older adults who remain sexually active tend to be healthier. And while there are considerable changes in a woman’s body with aging, the majority of women in their midlife and older who remain sexually active find that sexuality is very important to their well-being. Addressing any sexual health issues with your health care practitioner can help you better understand the challenges contributing to dissatisfaction and can lead to treatments that can improve not only your sexual health, but also your overall sense of well-being.

Content courtesy of Colleen Christmas, M.D., associate professor of medicine at the Johns Hopkins University School of Medicine. Content reproduced with permission of the Office of Marketing and Communications for Johns Hopkins Medicine International. Additional reuse and reprinting is not allowed. The information aims to educate readers and is not a substitute for consultation with a physician.

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