The Menopause

The menopause incorporates changes related to ageing, hormonal decline and altered social roles. Studies of the menopause and sexual relationships have reported a reduction in sexual activity with age. However, a US study of 18- to 59-year-old adults has reported sexual difficulties in 43 per cent of women and 31 per cent of men, i.e. a large proportion of the younger population [2]. An Australian longitudinal study, observing women from the age of 45 to 55, suggested that female sexual dysfunction increased from 42 to 88 per cent from the early to late menopause [3]. However, if ‘distress’ is included in the definition of female sexual dysfunction, this is reduced significantly [4]. As an indicator of the many factors, there is a small variation amongst European women, country by country, which indicates that the frequency of intercourse varies, but body mass index (BMI) is the only significant influencer.

However, there are well-documented increasing sexual difficulties with age: in women, these may be correlated with estrogen levels, but not consistently androgens, although testosterone levels have also not consistently been shown to reflect sexual functioning in younger women either. Predictably, women who have a sexual partner are more likely to be sexually active and to have increased satisfaction within their relationship. Cessation of sexual activity is more likely to be male-partner-driven within a relationship. A lifestyle survey from the UK, published in 2013, indicated that sexual inactivity was more common with reducing health status in both men and women, and therefore with age. One in six people reported a health condition that affected their sex life in the previous year: 24 per cent of men and 18 per cent of women had sought help or advice from a health care professional. Men report an increase in ejaculation and satisfaction problems, but less erectile dysfunction, although the wide availability of phosphodiesterase inhibitors may have changed the distribution of sexual problems in men (and the likelihood of seeking professional help). In women, sexual satisfaction rates have been increasing overall and have been linked with earlier sexual debut and more positive attitudes to female sexuality [5]. There is a greater expectation in women to continue to be sexually active and satisfied, but this is not universal. The change in social status and role of older women within their family, workplace and society in general contributes to the psychological overlay of sexual behaviour and responsivity. Individual preconceptions regarding ageing and behaviour vary hugely and overall knowledge is poor regarding the management of sexual problems in peri- and postmenopausal women. These culturally influenced factors will determine help-seeking attitudes.

Although many studies have been contradictory with respect to menopause and the cause of sexual difficulties being age or hormone related, overall when dealing with individual patients, the patient will be the ‘expert’ in her condition. The clinician needs to help her unravel the issues around cause and effect and determine the degree of distress.

Sexual Disorders

The Diagnostic and Statistical Manual of Mental Disorders (DSM) V classification now combines desire and arousal disorders as they are almost invariably linked. Isolated genital arousal disorder may, however, exist in postmenopausal women due to the physical changes of the menopause causing vulvo-vaginal atrophy. Over time this condition is commonly associated with reduced desire. Development of desire disorder may be protective from distress and dissatisfaction when preceded by dyspareunia or adverse changes in sexual responsivity.

Orgasmic disorders are a separate category, which may include a lack of or reduction in quality of sex, sometimes due to direct hormonal deficiencies or a culmination of other sexual issues. Dyspareunia and vaginismus are now also classified together, but are separate from non-coital pain disorders, which can also cause severe sexual dysfunction, for example vulvodynia and bladder pain syndrome.

The duration of the problem is an important factor in diagnosis of female sexual dysfunction. Short-term issues may be normal and a manifestation of the effects of life circumstances. Sexual difficulties may also reflect the overall psychological well-being of the individual. Of importance in the menopausal woman are the organic causes of sexual problems that may impact on psychological health. The etiological routes of anatomic, hormonal, neurologic, vascular and other abnormalities affect sexual self-esteem and functioning, given that sex is a mind and body activity.

However the academic study of sex should only inform the individual consultation – pathway-driven health care is most likely to fail where the emphasis of contributory factors is an individual response.

Sexual Response Cycle

Although the Masters and Johnson model of human sexuality [6] has been useful in explaining the sequence of phases in the human sexual response cycle, the Basson model of female sexuality [7] facilitates a clearer understanding of the drivers and difficulties specifically involved in the female sexual response cycle. A spontaneous drive to be sexually active may be less significant in a longstanding relationship than the need for emotional and physical satisfaction, and emotional and physical intimacy. A sexually neutral woman is able to be receptive to sexual stimuli in the right circumstances, and desire and arousal may occur concomitantly, rather than desire being a driver for activity. A better understanding of her emotional and relationship issues can be crucial to understanding the physical responses of a woman, particularly with the major life changes occurring at the menopause. How she perceives the changes happening to her, including her role in society, at work and within her family, all reflect her self-esteem and sexual confidence.

Management

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