Factors affecting sexual functioning of women in the mid-life years

Age Effects on Women's and Men's Dyadic and Solitary Sexual Desire

While most studies on sexuality in later life report that sexual desire declines with age, little is known about the exact nature of age effects on sexual desire. Using self-reported dyadic sexual desire relating to a partner, dyadic sexual desire relating to an attractive person, and solitary sexual desire from a large (N > 8000) and age diverse (14.6-80.2 years) online sample, the current study had three goals: First, we investigated relationships between men and women's sexual desire and age. Second, we examined whether individual differences such as gender/sex, sexual orientation, self-rated masculinity, relationship status, self-rated attractiveness, and self-rated health predict sexual desire. Third, we examined how these associations differed across sexual desire facets. On average, the associations between age and both men and women's sexual desire followed nonlinear trends and differed between genders/sexes and types of sexual desire. Average levels of all types of sexual desire were generally higher in men. Dyadic sexual desire related positively to self-rated masculinity and having a romantic partner and solitary desire was higher in people with same-sex attraction. We discuss the results in the context of the evolutionary hypothesis that predict an increase of sexual desire and female reproductive effort prior to declining fertility. Our findings both support and challenge beliefs about gender/sex specificity of age effects on sexual desire and highlight the importance of differentiating between desire types.

Predictive Factors for the Risk of Sexual Dysfunction in Climacteric Women: Population-based Study

BACKGROUND

It is known that sexual problems increase with age but little is known about the predictors of female sexual dysfunction (FSD) in Brazilian climacteric women.

AIM

To identify predictive factors for FSD in climacteric women.

METHODS

This is a cross-sectional population-based study carried out through a household survey.

OUTCOMES

The measures investigated were sociodemographic characteristics, depressive symptoms, level of physical activity, presence of FSD, self-rated health and sleep satisfaction.

RESULT

A total of 381 climacteric, sexually active women were included, with a mean age of 55.04 (±7.21) years. The prevalence of FSD was 38.3%. All variables investigated were associated with FSD (P < .05). In the final model, the predictors for FSD were low satisfaction with sleep (OR 4.20; 95% CI 2.32-7.62), advanced age (OR 1.04; 95% CI 1.00-1.08), low education level (OR 0.90; 95% CI 0.85-0.97) and having a partner (OR 0.35; 95% CI 0.16-0.76).

CLINICAL IMPLICATION

These aspects deserve attention from the health team to prevent and identify FSD early in life in climacteric women.

STRENGTHS & LIMITATIONS

This study support existing data about risk factors for FSD in climacteric women. However, it is not possible to attribute causality to any of the correlates identified, which is a limitation of cross-sectional studies.

CONCLUSION

Dissatisfaction with sleep, senility, insufficient income, low education, not having a partner, complaints of depression, and the worse perception of global health are predictive factors for FSD in climacteric women.

The Effect of Type of Delivery on Female Postpartum Sexual Functioning: A Systematic Review

Female sexual function could be considered as multifactorial. Specific physiological structures and hormonal fluctuations postpartum, along with the psychological adjustment of women, could result in altered sexual function. The primary aim of this review was to systematically appraise the existing data on the effect of mode of delivery on female sexual function. This review was designed based on the PRISMA statement guidelines. An extensive literature search was performed in the Pubmed, Scopus, and PsycInfo databases, using prespecified inclusion/exclusion criteria, between the 20 September and 10 October 2021. Studies’ quality assessment was conducted using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies of the National Heart, Lung, and Blood Institute. The initial search involved 1592 studies. The last step of the screening procedure yielded 16 studies, including 41,441 subjects with a mean age of 29.9 years. Studies included groups with spontaneous and assisted vaginal and C-section delivery modes. No statistically significant difference between groups was found. The type of delivery appears to be irrelevant regarding this relationship. Moderating factors seemed to indirectly influence this relationship. Health professionals should educate expectant mothers and be aware of the possibility that delivery method could affect sexual function.

Using Three Indirect Measures to Assess the Role of Sexuality-Related Associations and Interpretations for Women's Sexual Desire: An Internet-Based Experimental Study

Theoretical models emphasize the role of both automatic appraisals (i.e., associations) and conscious appraisals (i.e., interpretations) for sexual desire. Studies on sexuality-related appraisals have not combined self-report measures and experimental paradigms in order to compare the relevance of associations or interpretations. The aim of this study was to assess the relative contribution of both associations and interpretations to the explanation of low sexual desire in women. Toward this goal, indirect measures assessing associations (via a Single Target Implicit Association Test [STIAT]) and interpretations (via a Scrambled Sentences Test [SST] and a scenario task) were administered in a sample of 263 women (M_age = 27.90, SD 8.27) with varying levels of sexual desire and different sexual orientations (exclusively heterosexual women: 54.6%). Negative sexuality-related interpretations as assessed with two variants of the SST as well as the scenario task added to the explanation of lower sexual desire in women. Negative associations as measured with the STIAT were predictive of lower sexual desire only in women who did not indicate an exclusively heterosexual orientation. In this study, sexuality-related interpretations were more relevant to women's sexual desire than automatic associations. Future studies should assess the causal mechanism underlying sexuality-related interpretations (e.g., by evaluating whether these can be changed via cognitive bias modification techniques or psychological treatments).

Exploring Determinants of Sexual Satisfaction in a Chilean Representative Sample

This article examines the relationship between sexual satisfaction and gender, age, social status, being in stable relationships, intercourse frequency, and satisfaction with physical attractiveness (physical appearance and sex appeal). A self-report questionnaire was applied in a representative sample of 767 residents of Santiago (Chile), over 18 years old and that have had, at least, one sexual relation (with penetration) during their lives. Higher sexual satisfaction was predicted negatively by age and positively by higher satisfaction with sex appeal, higher intercourse frequency and having a stable relationship. Among women, the principal predictors are satisfaction with sex appeal and intercourse frequency. Among men to the above, it is necessary to add satisfaction with physical appearance and having a stable relationship - at odds with supposed higher relevance for women of body satisfaction and sensibility to social relationships. Discussion emphasizes the controversial nature of the gender differences found regarding the Latin American culture.

The Relational and Bodily Experiences Theory of Sexual Desire in Women

We review the theory and research on women's sexual desire and present a theory that incorporates internalized representations of relational and bodily experiences into our understanding of the full range of desire in women. To this end, we move away from the current tendency to focus on low sexual desire in women and instead consider desire on a spectrum or continuum from absent or diminished to high desire across multiple sexual orientations, including heterosexual, bisexual, and lesbian. We review definitions of sexual desire, as well as the epidemiology and etiology of hypoactive sexual desire, the most prevalent sexual complaint in women, including the biological, psychological, and relationship correlates of inhibited sexual desire. Subsequently, we examine the research on highly sexual women, who tend to experience high levels of sexual desire, sexual agency, and sexual esteem, and distinguish between high sexual desire and hypersexuality. We introduce two important constructs that are integrated into the Relational and Bodily Experiences Theory (RBET) of sexual desire in women: attachment and sexual body self-representations, suggesting that women's internalized representations of self and other that stem from childhood and their capacity to embody their sexual bodies are integral to our understanding of the phenomenology of sexual desire in women. RBET calls for further research into the links between attachment, sexual body self-representations, and desire, and suggests that clinical interventions for sexual desire difficulties in women should emphasize internalized working models of relationships (i.e., attachment) and integrate bodily based approaches.

Sexual Function and Factors Affecting Menopause: A Systematic Review

The purpose of this review study is to evaluate sexual function and its effective factors in menopause. A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The key words of “menopause,” “postmenopause,” “postmenopausal,” “premenopause,” “pre-menopausal period,” “sexual function,” “sexual health,” “sexuality,” “sexual and gender disorders,” “sexual development,” “sexual dysfunction,” “sexual disorders,” “sexual behavior and “sexual activity” were used in combination with the Boolean operators OR and AND. After reviewing the selected articles, 27 papers were selected based on the criteria for entering the study and the goals set. The results of the reviewed articles showed that, in the physical domain, the factors affecting sexual function can be mentioned, age, hormonal changes, medical problems and reproductive history. Sexual disorders in menopause can be affected by some of the individual and social characteristics and psychological problems. Considering the fact that many psychological and social injuries occur in this period following sexual disorders; therefore, policies and programs for improving the quality of life of women in menopause should be aimed at eliminating sexual dysfunction, correcting attitudes and negative emotions and help to women for more comfortable in menopause.

Sexual functioning after total versus subtotal laparoscopic hysterectomy

AIM

To evaluate postoperative sexual functioning and the influence of patients' expectations on the change in sexuality following laparoscopic total (TLH) versus subtotal hysterectomy (LASH).

METHODS

A total of 120 women undergoing laparoscopic hysterectomy were preoperatively enrolled in this bicentric prospective study. Sexual functioning (SF) was evaluated using the female sexual function index (FSFI). Additionally, participants filled in a standardised questionnaire concerning expected changes in SF after surgery. At 3, 6 and 12 months following surgery, women were asked again to assess their level of SF (FSFI). Data of women who participated in at least one FSFI follow-up assessment were analysed (n = 92). We compared the change in SF after surgery between patients with TLH (n = 46) and LASH (n = 46). Additionally, we calculated regression analyses with the patients' expectations as a predictor for change in FSFI scores.

RESULTS

Comparing the change of FSFI scores after surgery in both collectives revealed differences only 3 months after surgery, as improvement was stronger for the LASH collective compared to the THL group (p = 0.006). There were no changes comparing collectives after 6 (p = 0.663) and 12 (p = 0.326) months. Concerning patients' expectations, for the LASH group baseline SF (p < 0.001), but not expectations (p = 0.567) predicted the strength of change at each of the follow ups: a lower level of baseline SF was linked to a stronger improvement after surgery. For the THL collective, both baseline SF (p < 0.001) as well as patients' expectations (3 months: p = 0.077, 6 months: p = 0.37, 12 months: p = 0.024) predicted the strength of change: both, a lower level of baseline SF and higher expectations towards an improvement predicted a stronger improvement.

CONCLUSION

The preservation of the cervix does not show an advantage in improving SF after surgery. Both methods induce a comparable improvement in long-time SF, especially in patients with an impaired sexuality pre-surgery. Furthermore, patients' expectations concerning this matter seem to have an impact on the postoperative outcome; therefore, this circumstance should be considered in future projects.

Prevalence of sexual dysfunction in infertile versus fertile couples

OBJECTIVES

The primary aim of this study was to test the hypothesis that sexual dysfunction is higher in infertile females in relation to normal healthy women through comparing total and sexual domains scores in both groups. The secondary objectives were: to determine factors affecting occurrence of female sexual dysfunction (FSD) in all sample and to determine factors affecting the different sexual domain scores within the infertile group.

STUDY DESIGN

This cross sectional study was done at Cairo University Hospital. 200 infertile and 200 control females were evaluated using the Female Sexual Function Index (FSFI) questionnaire. Total score less than 26.55 signified sexual dysfunction. Husbands were evaluated by Sexual Health Inventory for Men (SHIM) questionnaire. A score less than 22 signified erectile dysfunction (ED).

RESULTS

Proportion of females with sexual dysfunction was higher in the infertile versus control group (47% versus 30%, 95%CI for the difference: 8%, 26%, p-value:<0.001). Total, orgasm, satisfaction and pain scores were significantly lower in infertile versus control group (mean±SD: 26.8±3.8 versus 27.9±3.5, p-value: 0.003; 4.2±0.7 versus 4.6±0.6, p-value: 0.01; 4.9±0.5 versus 5.2±0.5, p-value: 0.004 and 3.9±0.9 versus 4.4±0.7, p-value:<0.001 respectively). Husband SHIM erectile score was significantly lower in the infertile group (median score (range): 19 (5, 25) versus 22 (12, 25), p-value: 0.001). After adjustment for 15factors by logistic regression, the odds ratio of having FSD was 2.6 (95%CI: 1.5, 4.5, p-value: 0.001) in the infertile relative to control females. Secondary (versus primary) infertility was negatively correlated with arousal score (B (95%CI): -0.6 (-0.02, -1.2), p-value: 0.003) while duration of infertility was negatively correlated with arousal, satisfaction and pain domains scores (B (95%CI): -0.2 (-0.08, -0.32), p-value: 0.04; -0.2 (-0.1, -0.3), p-value: 0.005; -0.2 (-0.06, -0.34), p-value: 0.03 respectively).

CONCLUSION

sexual dysfunction is more prevalent in infertile versus control group. Infertility clinicians should be aware of this problem to assess and treat their patients to improve their quality of life.

Postoperative sexual functioning in total versus subtotal laparoscopic hysterectomy: what do women expect?

PURPOSE

To evaluate sexual functioning and expected changes in sexual functioning in women with planned total versus subtotal laparoscopic hysterectomy.

METHODS

A total of 120 women undergoing laparoscopic hysterectomy were preoperatively enrolled in this study with a cross-sectional design. Full data sets were available for 112 patients, so that 56 patients with planned total laparoscopic hysterectomy (TLH) and 56 women with planned laparoscopic supracervical hysterectomy (LASH) were preoperatively assessed. Sexual functioning was evaluated using the female sexual function index (FSFI). Additionally, participants filled in a standardised questionnaire concerning expected changes on sexual function after the procedure. Demographic parameters, expectations concerning postoperative sexuality and FSFI scores were analysed and compared in women undergoing TLH and LASH.

RESULTS

There were no significant differences concerning demographic parameters and FSFI scores comparing collectives. Sexuality in general was considered more important in women undergoing LASH (2.88 ± 0.83 vs. 2.48 ± 0.89; p = 0.011). Also, in 29 patients (52%) opting for LASH and 8 (14%) patients undergoing TLH a potential change in postoperative sexuality had an impact on their choice for a subtotal/total hysterectomy, respectively (p < 0.001).

CONCLUSION

Patients' expectations concerning preservation of the cervix and postoperative sexuality appear to have the potential to bias investigations comparing total with subtotal hysterectomy. Hence, future research focusing on this issue should be accomplished incorporating patients' expectations stratified by mode of intervention.

Evidence-based treatments for low sexual desire in women

Low sexual desire is the most common sexual complaint in women, with multinational studies finding that at least a third of women experience low sexual desire. No single etiology for the development of Female Sexual Interest/Arousal Disorder, the diagnosis laid out by the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders, has been established. There has been considerable interest in pharmacological approaches to improving low desire, and agents targeting a range of neurotransmitters have been examined. To date, only flibanserin, a centrally acting medication targeting the serotonin, dopamine, and norepinephrine systems, has been approved by the Food and Drug Administration (FDA). Despite statistically significant effects on sexual desire, sexual distress, and sexually satisfying events, side-effects are significant, and flibanserin is completely contraindicated with alcohol. As such, there has been renewed interest in advancing the science of psychological approaches to low desire, including cognitive behavioral and mindfulness therapies.

Cohort profile: Women's Healthy Ageing Project (WHAP) - a longitudinal prospective study of Australian women since 1990

Background

The cohort was commenced to examine women’s health from midlife (45–55 years) before the menopausal transition and into ageing.

Methods

Randomised selection and assessment of 2,001 women living in the Melbourne metropolitan area was conducted by the Roy Morgan Centre in 1990/91. Of the 779 women who met the entry criteria for the longitudinal follow-up (aged 45–55 years, menstruating, having a uterus and at least one ovary and not taking hormone therapy) 438 agreed to be seen annually across the menopausal transition from 1992 to 1999. Longitudinal prospective follow-up since 2000 has continued intermittently (2002/03, 2004/05, 2012/13, 2014/15). Data collection has included fasting biomarkers in each year since 1992, clinical assessment, lifestyle and quality of life data, physical measures and validated questionnaire data. Participants have consented to data linkage and, to date, mammogram and BioGrid data have been accessed. Biobank storage including serum, deoxyribonucleic acid (DNA) storage and PAXgene tubes are maintained.

Discussion

The WHAP has contributed to over 200 published research findings, several books, and book chapters in a variety of areas, including: health and wellbeing; mental and cognitive health; bone health; lifestyle, vascular risk and prevention; women’s health and hormonal transition; and cross-cultural research.

With all participants now aged over 70 years, the cohort is ideally placed to answer key questions of healthy ageing in women. With more than 25 years of longitudinal prospective follow-up this Australian dataset is unique in its duration, breadth and detail of measures including clinical review and specialized disease-specific testing and biomarkers. Ongoing follow-up into older ages for this long-running cohort will enable the association between mid to late-life factors and healthy ageing to be determined. This is particularly valuable for the examination of chronic diseases which have a 20–30 year prodrome and to provide knowledge on multiple morbidities. The dataset has a unique opportunity to improve our understanding of temporal relationships and the interactions between risk factors and comorbidities.

Electronic supplementary material

The online version of this article (doi:10.1186/s40695-016-0018-y) contains supplementary material, which is available to authorized users.

Associations between body mass index and sexual functioning in midlife women: the Study of Women's Health Across the Nation

OBJECTIVE

This study aims to examine baseline and longitudinal associations between body mass index (BMI) and sexual functioning in midlife women.

METHODS

Midlife women (N = 2,528) from the Study of Women's Health Across the Nation reported on sexual functioning and underwent measurements of BMI annually beginning in 1995-1997, with follow-up spanning 13.8 years. Associations between baseline levels and longitudinal changes in BMI and sexual desire, arousal, intercourse frequency, and ability to climax were assessed with generalized linear mixed-effects models. Models were adjusted for demographic variables, depressive symptoms, hormone therapy use, alcohol intake, menopause status, smoking status, and health status.

RESULTS

Mean BMI increased from 27.7 to 29.1 kg/m2, whereas all sexual functioning variables declined across time (P values ≤ 0.001). Higher baseline BMI was associated with less frequent intercourse (P = 0.003; 95% CI, -0.059 to -0.012). Although overall change in BMI was not associated with changes in sexual functioning, years of greater-than-expected BMI increases relative to women's overall BMI change trajectory were characterized by less frequent intercourse (P < 0.001; 95% CI, -0.106 to -0.029) and reduced sexual desire (P = 0.020; 95% CI, -0.078 to -0.007).

CONCLUSIONS

Although women's overall BMI change across 13.8 years of follow-up was not associated with overall changes in sexual functioning, sexual desire and intercourse frequency diminished with years of greater-than-expected weight gain. Results suggest that adiposity and sexual functioning change concurrently from year to year. Further research should explore the impact of weight management interventions as a strategy for preserving sexual functioning in midlife women.

A biopsychosocial approach to women's sexual function and dysfunction at midlife: A narrative review

A satisfying sex life is an important component of overall well-being, but sexual dysfunction is common, especially in midlife women. The aim of this review is (a) to define sexual function and dysfunction, (b) to present theoretical models of female sexual response, (c) to examine longitudinal studies of how sexual function changes during midlife, and (d) to review treatment options. Four types of female sexual dysfunction are currently recognized: Female Orgasmic Disorder, Female Sexual Interest/Arousal Disorder, Genito-Pelvic Pain/Penetration Disorder, and Substance/Medication-Induced Sexual Dysfunction. However, optimal sexual function transcends the simple absence of dysfunction. A biopsychosocial approach that simultaneously considers physical, psychological, sociocultural, and interpersonal factors is necessary to guide research and clinical care regarding women's sexual function. Most longitudinal studies reveal an association between advancing menopause status and worsening sexual function. Psychosocial variables, such as availability of a partner, relationship quality, and psychological functioning, also play an integral role. Future directions for research should include deepening our understanding of how sexual function changes with aging and developing safe and effective approaches to optimizing women's sexual function with aging. Overall, holistic, biopsychosocial approaches to women's sexual function are necessary to fully understand and treat this key component of midlife women's well-being.

The Association Between Female Sexual Dysfunction and the Husband's Erectile Dysfunction: Evidence from Married Couples in Hong Kong

Little is known about the association between the sexual functioning of each partner in a heterosexual married couple. By using a community-based survey of Hong Kong Chinese couples in 2012, this study attempted to examine the relation between female sexual dysfunction and their husbands' erectile dysfunction. Among the 1,518 female and 1,059 male respondents, 944 sexually active couples were eligible for the analysis, with mean age of 39.3 ± 6.8 years (range = 21-50) for the wives and 43.6 ± 8.6 years (range = 18-80) for the husbands. Of the wives, 27.0% reported at least one form of female sexual dysfunction and 5.0% of the husbands reported erectile dysfunction. After adjusting for the female's age and other risk factors, the total and domain scores of female sexual dysfunction were not associated with her husband's erectile dysfunction except for physical pain during sexual intercourse. Therefore, whether to screen the partner's sexual function depends on the age of the female clients.

Dehydroepiandrosterone intra vaginal administration for the management of postmenopausal vulvovaginal atrophy

The effects of intravaginal administration of dehydroepiandrosterone (DHEA) for the management of symptomatic vulvovaginal atrophy are reviewed. A literature search related to vulvovaginal atrophy, vaginal atrophy, atrophic vaginitis, estrogen, dehydroepiandrosterone, vulvar itching, burning, dryness, dyspareunia, and libido was performed. Relevant articles addressing the incidence, management, and outcome of DHEA therapy were identified and used for this Expert Opinion. DHEA compared to a placebo is an effective treatment improving symptoms of vaginal atrophy: dyspareunia, burning, itching, and dryness. Objective parameters of vaginal atrophy, specifically pH, vaginal maturation index (VMI), and investigator-evaluated changes in the vagina: moisture, epithelia integrity and color were improved compared to baseline and placebo. There were significant improvements in libido and dyspareunia with the intravaginal use of DHEA that contribute to improved quality of life for postmenopausal women. Dehydroepiandrosterone administered intravaginally on a daily basis is an effective treatment for symptoms, and signs of vulvovaginal atrophy along with libido in postmenopausal women. This article is part of a Special Issue entitled 'Essential role of DHEA'.

The role of psychopathological and personality covariates in orgasmic difficulties: a prospective longitudinal evaluation in a cohort of women from age 30 to 50

INTRODUCTION

There are little published data on the prevalence of orgasmic difficulties in representative samples and no longitudinal data on the subject. In addition, our knowledge of the factors, which increase or protect against the risk of orgasmic difficulties, is still rudimentary.

AIM

The aim of this study was to evaluate the cumulative incidence rate and longitudinal course of orgasmic difficulties from age 30 to age 50, and the role of psychopathological and personality covariates in a representative population cohort of women.

METHODS

Semi-structured interviews with single-item questions on sexual problems in general as well as on orgasmic difficulties were conducted. Psychopathological covariates were from the Symptom Checklist 90 Revised and personality characteristics from the Freiburg Personality Inventory. Coping resources were measured by the scales of mastery and self-esteem.

MAIN OUTCOME MEASURES

One-year prevalences of orgasmic difficulties, associations with psychopathological and personality covariates as well as coping resources were the main outcome measures.

RESULTS

Orgasmic difficulties were reported annually by 7.4% to 13.5% of the women with a mean of 10.0% and a cumulative risk of 27.3% from age 30 to 50. No relation between age and the prevalence of orgasmic difficulties could be demonstrated. Psychopathological covariates such as depression, psychoticism, interpersonal sensitivity, obsessive-compulsive symptoms, and somatization were moderately associated with orgasmic difficulties. Also, personality traits, i.e., nervousness, aggressiveness, depressiveness, irritability, sociability, and openness, were related to orgasmic difficulties.

CONCLUSIONS

With a cumulative risk of 27.3%, orgasmic difficulties represent a frequent sexual problem. Annual prevalence rates are particularly high in women with psychopathological characteristics and modestly related to various personality traits. Our findings support the relevance of psychosocial factors in the regulation of female orgasm. More basic research is needed to better understand underlying pathophysiological mechanisms and to improve diagnostic as well as therapeutic tools for women suffering from orgasmic difficulties.

Group mindfulness-based therapy significantly improves sexual desire in women

At least a third of women across reproductive ages experience low sexual desire and impaired arousal. There is increasing evidence that mindfulness, defined as non-judgmental present moment awareness, may improve women's sexual functioning. The goal of this study was to test the effectiveness of mindfulness-based therapy, either immediately or after a 3-month waiting period, in women seeking treatment for low sexual desire and arousal. Women participated in four 90-min group sessions that included mindfulness meditation, cognitive therapy, and education. A total of 117 women were assigned to either the immediate treatment (n = 68, mean age 40.8 yrs) or delayed treatment (n = 49, mean age 42.2 yrs) group, in which women had two pre-treatment baseline assessments followed by treatment. A total of 95 women completed assessments through to the 6-month follow-up period. Compared to the delayed treatment control group, treatment significantly improved sexual desire, sexual arousal, lubrication, sexual satisfaction, and overall sexual functioning. Sex-related distress significantly decreased in both conditions, regardless of treatment, as did orgasmic difficulties and depressive symptoms. Increases in mindfulness and a reduction in depressive symptoms predicted improvements in sexual desire. Mindfulness-based group therapy significantly improved sexual desire and other indices of sexual response, and should be considered in the treatment of women's sexual dysfunction.

Management of symptomatic vulvovaginal atrophy: 2013 position statement of The North American Menopause Society

OBJECTIVE

To update and expand the previous position statement of The North American Menopause Society (NAMS) on the management of symptomatic vulvovaginal atrophy (VVA) in postmenopausal women.

METHODS

NAMS searched PubMed for medical literature on VVA published since their 2007 position statement on the role of local vaginal estrogen for treatment of vaginal atrophy in postmenopausal women. A panel of acknowledged experts in the field of genitourinary health reviewed the literature to evaluate new evidence on local estrogen as well as on other management options available or in development for symptomatic VVA. The panel's conclusions and recommendations were reviewed and approved by the NAMS Board of Trustees.

RESULTS

Symptomatic VVA can significantly impair the quality of life (QOL) of postmenopausal women and may be underdiagnosed. In most cases, it can be managed successfully. A number of over-the-counter and government-approved prescription therapies available in the United States and Canada demonstrate effectiveness, depending on the severity of VVA symptoms. These include vaginal lubricants and moisturizers, vaginal estrogen, hormone therapy, and the selective estrogen-receptor modulator ospemifene (indicated for dyspareunia). Long-term studies on the endometrial safety of local estrogen and ospemifene are lacking. Changes in the vaginal microbiome have various effects on symptoms.

CONCLUSIONS

Clinicians can improve the sexual health and QOL of postmenopausal women by educating women about, diagnosing, and appropriately managing symptomatic VVA. Choice of therapy depends on the severity of symptoms, the effectiveness and safety of therapy for the individual patient, and patient preference. Estrogen therapy is the most effective treatment for moderate to severe symptoms, although a direct comparison of estrogen and ospemifene is not available. Nonhormonal therapies available without a prescription provide sufficient relief for most women with mild symptoms. When low-dose estrogen is administered locally, a progestogen is not indicated for women without a uterus and generally is not indicated for women with an intact uterus. However, endometrial safety has not been studied in clinical trials beyond 1 year. There are insufficient data to confirm the safety of local estrogen in women with breast cancer; management of VVA should take the woman's needs and the recommendation of her oncologist into consideration. Research on the vaginal microbiome may lead to other therapies in the future.

[The couple: An essential entity?]

OBJECTIVE

To evaluate the urological management of the relationship of the couple with both male and female sexual dysfunction.

MATERIALS AND METHODS

Review of the guidelines published on this subject in the Medline database together with our own clinical experience in this field.

RESULTS

To optimize therapy the urologist should consider the couple when a patient presents with a sexual symptom otherwise the risk of inappropriate, unsuccessful treatment is high. If a dysfunctional relationship is clearly present, with major conflict between the partners or a marked lack of communication, these negative couples must be seen for sex therapy within a multidisciplinary approach. Even with a positive couple, without major conflict, it is advisory to include the partner in the diagnosis and the treatment, for her attitude as a factor which can influence the sexual motivation of the couple, the means and results of the management. In addition, poor knowledge of a sexual problem concerning the woman, whether this predates the partner's dysfunction or not, can impede the efficacy of pharmaceutical treatment.

CONCLUSION

Thus, the couple should be seen as a clinical entity with its own fulfillment, which plays an important role in treatment effectiveness, in compliance. Adapting the management to the real expectations of the patient and the couple is essential. With the possible help of the pharmacological treatments of sexual symptoms, a work on all aspects of the couple's dysfunction should bring a new harmony in sexual and affectionate aspects of the relationship.

The effects of chronic administration of testosterone propionate with or without estradiol on the sexual behavior and plasma steroid levels of aged female rats

Low sexual desire concomitant with feelings of distress is reported in naturally and surgically menopausal women. A combination of estradiol (E2) and testosterone (T) restores sexual desire and interest in these women. The central mechanisms by which E2 and T act to restore desire are poorly understood. Here we examined the effect of chronic treatment with testosterone propionate (TP) administered by a sc SILASTIC brand capsule in aged ovary-intact female rats. Females were first treated with TP alone, followed by a second phase when TP was administered in combination with estradiol benzoate (EB; 10 μg) by sc injection 48 h prior to testing (EB+TP). Each phase consisted of 5 test days at 4-d intervals. Appetitive and consummatory female sexual behaviors were observed in bilevel chambers, and plasma E2 and T concentrations were measured with ELISA. Sexual solicitations and hops and darts were facilitated by the highest TP dose, and the lordosis quotient was increased by the two highest TP doses when administered alone, coinciding with an increase in plasma T, but those behavioral effects were not maintained across time. The lordosis quotient was inversely related to the TP dose in the EB+TP phase. These results suggest that the administration of TP by sc capsules to aged female rats facilitates appetitive and consummatory sexual behaviors; however, chronic treatment appears to be inhibitory. This is the first study to assess sexual behavior after SILASTIC brand implants of TP in the aged female rat. Additional research is needed to elucidate the mechanisms underlying the effects of T on female sexual function.

[Sexuality of the elderly: a survey and management]

OBJECTIVE

To evaluate sexuality in elderly couples and have the knowledge of its specific therapeutic options.

MATERIAL AND METHODS

Review of articles published on this subject in the Medline database, selected according to their scientific relevance together with a reflexion from our own experience.

RESULTS

Due to increased life expectancy and the changes in society leading to a life with more than one consecutive partner, couples expect to continue sexual activity after the age of 65. Clinicians are asked to address this issue frequently. With age the frequency of genital sexual relations decreases. Sexual activity should be higher both for males and females. The quality of the relationship of the couple is a key element in maintaining sexual relations in this age group. Sexual satisfaction depends on the understanding, by both partners, of the physical and psychological changes due to increased age.

CONCLUSION

The sexuality of the elderly couple must be analysed using specific criteria. The clinician's task is to explain to the patients the physiological change due to aging and give them advice on how to adapt their sexual behavior accordingly. Management will, at the same time, include pharmacological treatment, notably for erectile dysfunction, in order to restore satisfactory sexual relations. For women, vaginal lubrication products are essential. This global management should allow many elderly couples wishing to continue sexual relations, to enjoy this period of their lives in harmony with what they desire.

Is female sexual function related to the male partners' erectile function?

INTRODUCTION

There are limited data concerning the relationship between the sexual functioning of each partner in a heterosexual couple.

AIM

This cross-sectional study was to investigate the association between female sexual function and the male partners' erectile function.

METHODS

Two self-administered questionnaires were used, one distributed to 2,159 female employees of two hospitals in Southern Taiwan and the other to their male partners, if available, to assess sexual function in each partner of the couple.

OUTCOME MEASURE

Female sexual function and male erectile function were assessed by the Female Sexual Function Index (FSFI) and by the International Index of Erectile Function (IIEF), respectively.

RESULTS

Among the 1,580 female and 779 male respondents, 632 sexually active couples were eligible for the analysis with mean ages of 36.9 years (range 21-67) and 39.5 years (range 18-80) for the women and men, respectively. After adjustment for female age group, nearly all the FSFI and IIEF domain scores correlated significantly to a slight to moderate degree. On the basis of the FSFI and IIEF scores, 42.9% (255/594) of the women reported sexual difficulty, and 15.0% (96/632) of the men reported mild to moderate erectile dysfunction (ED). After adjustment for female age group, the female partners of men with ED had significantly lower total and domain scores of the FSFI than those of men without ED, with effect sizes of η(p)(2) = 0.02-0.08. After further adjustment for other risk factors, ED of the male partner was still a significant risk factor for female sexual difficulty as well as for sexual difficulty in the aspects of arousal, orgasm, sexual satisfaction, and sexual pain (odds ratio = 2.5-3.3).

CONCLUSIONS

Significant correlations between female sexual functioning and male erectile function were identified.

Testosterone and libido in surgically and naturally menopausal women

The assessment and then treatment of a change in libido, or a change in the desire to partake in sexual activity, during the menopausal transition and beyond has been a challenging and elusive area of clinical research. This is partly due to the multidimensional nature of female sexuality, the difficulties of measuring testosterone in women in a reliable and accurate manner, and the complexity of the neurobiology and neurobehavior of female sexual desire. In addition, there is a lack of evidence for diagnostic specificity of low free testosterone levels for the symptom of low libido in women for whom there are no confounding interpersonal or psychological factors; although, in the symptomatic population of surgically or naturally menopausal women, a low level of free testosterone often accompanies a complaint of reduced desire/libido. The randomized clinical trial research on testosterone replacement for naturally and/or surgically menopausal women with sexual dysfunction has been criticized for a high placebo response rate, supraphysiological replacement levels of testosterone, the perception of modest clinical outcome when measuring objective data such as the frequency of sexual intercourse relative to placebo, and the unknown safety of long-term testosterone replacement in the estrogen-replete surgically or naturally menopausal woman. A careful review of current evidence from randomized, controlled trials lends support to the value of the replacement of testosterone in the estrogen-replete menopausal woman for whom libido and desire has declined. The issue of long-term safety remains to be answered.

Genetic and Environmental Influences on the Frequency of Orgasm in Women

This study reports on genetic and environmental influences on the frequency of orgasm in women during sexual intercourse, during other sexual contact with a partner, and during masturbation. Participants were drawn from the Australian Twin Registry, and recruited from a large, partly longitudinal twin-family study. Three thousand and eighty women responded to the anonymous self-report questionnaire, including 667 complete monozygotic (MZ) pairs and 377 complete dizygotic (DZ) same-sex pairs, 366 women from complete DZ opposite-sex pairs, and 626 women whose co-twins did not participate. Significant twin correlations were found for both MZ and DZ twin pairs for all three items of interest. Age effects were statistically significant for some items. Models incorporating additive genetic, shared and nonshared environmental influences provided the best fit for Items 1 and 3, while a model with additive and nonadditive genetic influences along with nonshared envir-onment fitted the data from Item 2. While an independent pathway model fits the data most par-simoniously, a common pathway model incorporating additive genetic (A), shared environment (C), and unique environment (E) effects cannot be ruled out. Overall, genetic influences account for approximately 31% of the variance of frequency of orgasm during sexual intercourse, 37% of the variance of frequency of orgasm during sexual contact other than during intercourse, and 51% of the variance of frequency of orgasm during masturbation. Following Baker (1996), we speculate that this additive genetic variance might arise from frequency-dependent selection for a variety of female sexual strategies.

Measuring sexual function in community surveys: development of a conceptual framework

Among the many psychometric measures of sexual (dys)function, none is entirely suited to use in community surveys. Faced with the need to include a brief and non-intrusive measure of sexual function in a general population survey, a new measure was developed. Findings from qualitative research with men and women in the community designed to inform the conceptual framework for this measure are presented. Thirty-two semi-structured interviews with individuals recruited from a general practice, an HIV/AIDS charity, and a sexual problems clinic were conducted. From their accounts, 31 potential criteria of a functional sex life were identified. Using evidence from qualitative data and the existing literature, and applying a set of decision rules, the list was reduced to 13 (eight for those not in a relationship), and a further eight criteria were added to enable individuals to self-rate their level of function and indicate the severity of difficulties. These criteria constitute a conceptual framework that is grounded in participant perceptions; is relevant to all, regardless of sexual experience or orientation; provides opportunity to state the degree of associated distress; and incorporates relational, psychological, and physiological aspects. It provides the conceptual basis for a concise and acceptable measure of sexual function.

Urogenital complaints and female sexual dysfunction. Part 2

INTRODUCTION

Female sexual dysfunction (FSD) is common in women with urogenital disorders that occur as a result of pelvic floor muscle and fascial laxity.

AIM

Provide a comprehensive review of FSD as it relates to common urogenital disorders including pelvic organ prolapse (POP) and stress urinary incontinence (SUI) and to discuss the impact of the surgical repair of these disorders on sexual function.

METHODS

Systematic search of the medical literature using a number of related terms including FSD, POP, SUI, surgical repair, graft augmentation, complications, and dyspareunia.

MAIN OUTCOME MEASURES

Review of the medical literature to identify the relation between FSD and common urogenital disorders in women and to describe appropriate treatment strategies to improve quality of life (QOL) and sexual function.

RESULTS

FSD is common in women with POP and SUI. Treatment options for POP and SUI include behavioral, pharmacological, and surgical methods which can also affect sexual function.

CONCLUSIONS

Sexual dysfunction is a common, underestimated complaint in women with POP and SUI. Treatment should be tailored toward improving sexual function and QOL. Surgical correction is generally beneficial but occasionally can result in negative alterations in sexual function. Patient selection and methods used for surgical repair are important factors in determining anatomical and functional success.

Dyspareunia is associated with decreased frequency of intercourse in the menopausal transition

OBJECTIVE

The frequency of sexual intercourse declines as women enter midlife. Whereas partner availability and function probably play a role, menopausal symptoms, such as vaginal dryness, are also present. We examine the associations among vaginal dryness, dyspareunia, and frequency of sexual intercourse.

METHODS

In the second year of a longitudinal study, women completed questionnaires that included menopause status and symptoms, participation in sexual activities, dyspareunia, marital status, and race. We used univariable and multivariable ordered logistic regression models to examine the associations among the frequency of sexual intercourse, vaginal dryness, use of lubrication during sex, and dyspareunia.

RESULTS

In multivariable analyses of the 363 sexually active women with complete data, women reporting more frequent dyspareunia, but not vaginal dryness, also reported less frequent intercourse. Advancing menopause status was associated with lower frequency of intercourse, whereas age was not. Dyspareunia and vaginal dryness were only moderately correlated (r = 0.4).

CONCLUSIONS

Women continue to participate in sexual intercourse through midlife. Women who report dyspareunia, but not vaginal dryness, report less frequent intercourse. Relief of dyspareunia should be addressed to maintain sexual functioning during midlife.

Vaginal estrogens for the treatment of dyspareunia

INTRODUCTION

Vaginal atrophy, which is associated with vaginal itching, burning, dryness, irritation, and pain, is estimated to affect up to 40% of postmenopausal women. Estrogens play a key role in maintaining vaginal health; women with low serum estradiol are more likely to experience vaginal dryness, dyspareunia, and reduced sexual activity compared with women who have higher estradiol levels.

AIMS

The purpose of this review is to assess the prevalence and impact of dyspareunia, a symptom of vaginal atrophy, on the health of postmenopausal women and to evaluate treatment options using vaginal estrogens (U.S. Food and Drug Administration [FDA] approved).

METHODS

Relevant published literature was identified by searching Index Medicus using the PubMed online database. The search terms dyspareunia, vaginal estrogen, vaginal hormone therapy, vaginal atrophy, and atrophic vaginitis were the focus of the literature review.

RESULTS

Current treatment guidelines for vaginal atrophy recommend the use of minimally absorbed local vaginal estrogens, along with non-hormonal lubricants or moisturizers, coupled with maintenance of sexual activity. Vaginal estrogen therapy has been shown to provide improvement in the signs and symptoms of vaginal or vulvar atrophy. Vaginal tablets, rings, and creams are indicated for the treatment of vaginal atrophy, and the FDA has recently approved a low-dose regimen of conjugated estrogens cream to treat moderate-to-severe postmenopausal dyspareunia. The use of low-dose vaginal estrogens has been shown to be effective in treating symptoms of vaginal atrophy without causing significant proliferation of the endometrial lining, and no significant differences have been seen among vaginal preparations in terms of endometrial safety.

CONCLUSION

Women should be informed of the potential benefits and risks of the treatment options available, and with the help of their healthcare provider, choose an intervention that is most suitable to their individual needs and circumstances.

Menopause, depression, and loss of sexual desire: a psychodynamic contribution

Menopause is a phase of life during which physiological and psychological symptoms may occur. Most women traverse the menopausal transition without significant morbidity. The descriptive literature on menopause indicates that the nature of psychological and physical morbidity is a function of a variety of bio-psychosocial influences. There are distinct subgroups of women who are more likely to become symptomatic during this phase. Rosemary Basson has reconceptualized the female sexual response cycle. Her model allows the clinician to better understand and treat the reciprocal, interacting influences of depression, menopausal changes, and decreases in sexual desire on sexual functioning. Psychodynamic theories about menopause have moved away from the early models which predicted a universally negative experience. It is now believed that past psychological and medical problems, trauma, and the quality of interpersonal relationships are important predictors for the development of symptoms. Psychodynamic psychotherapy, in conjunction with psychoeducation, pharmacotherapy and hormone replacement therapy (HRT) may all be helpful in the treatment of symptoms.

The menopausal transition: a 9-year prospective population-based study. The Melbourne Women's Midlife Health Project

OBJECTIVES

To describe the natural history of the menopause in Australian-born women. To determine the hormonal changes relating to the menopausal transition (MT) and how these affect quality of life, bone mineral density, body composition, cardiovascular disease (CVD) risk and memory.

DESIGN

A 9-year prospective, observational study of a population-based sample of 438 Australian-born women aged 45-55 years at baseline. By the 9th year, the retention rate was 88%. Interviews, blood sampling, menstrual calendars, quality of life and physical measures were taken annually, and bone mineral density was measured bi-annually.

RESULTS

The late MT coincides with changes in estradiol, follicle stimulating hormone, and free testosterone index, decreases in bone density and mastalgia, and increases in central adiposity, vasomotor symptoms, insomnia and vaginal dryness. Levels of total testosterone and dehydroepiandrosterone sulfate are unchanged by the MT. An increase in CVD risk was associated with increases in weight and free testosterone index and a decrease in estradiol. Depressed mood is increased by symptoms and by stressors occurring in the MT. Sexual functioning significantly deteriorates with the MT and aging, but relational factors have major effects. Menstrual cycles became more variable and longer closer to the final menstrual period.

CONCLUSIONS

As hormonal changes during the MT directly or indirectly adversely affect quality of life, body composition and CVD risk, maintenance of health parameters in the premenopausal years is crucial for a healthy postmenopause.

The DSM diagnostic criteria for female orgasmic disorder

This article reviews the DSM diagnostic criteria for Female Orgasmic Disorder (FOD). Following an overview of the concept of female orgasm, research on the prevalence and associated features of FOD is briefly reviewed. Specific aspects of the DSM-IV-TR criteria for FOD are critically reviewed and key issues that should be considered for DSM-V are discussed. The DSM-IV-TR text on FOD focused on the physiological changes that may (or may not) accompany orgasm in women; one of the major recommendations here is that greater emphasis be given to the subjective aspects of the experience of orgasm. Additional specific recommendations are made for revision of diagnostic criteria, including the use of minimum severity and duration criteria, and better acknowledgment of the crucial role of relationship factors in FOD.

Longitudinal changes in sexual functioning as women transition through menopause: results from the Study of Women's Health Across the Nation

OBJECTIVE

Sexual functioning is an important component of women's lives. The extent to which the menopausal transition is associated with decreased sexual functioning remains inconclusive. This study seeks to determine if advancing through the menopausal transition is associated with changes in sexual functioning.

METHODS

This was a prospective, longitudinal cohort study of women aged 42 to 52 years at baseline recruited at seven US sites (N = 3,302) in the Study of Women's Health Across the Nation (SWAN). Cohort-eligible women had an intact uterus, had at least one ovary, were not currently using exogenous hormones, were either premenopausal or early perimenopausal, and self-identified as one of the study's designated racial/ethnic groups. Data from the baseline interview and six annual follow-up visits are reported. Outcomes are self-reported ratings of importance of sex; frequency of sexual desire, arousal, masturbation, sexual intercourse, and pain during intercourse; and degree of emotional satisfaction and physical pleasure.

RESULTS

With adjustment for baseline age, chronological aging, and relevant social, health, and psychological parameters, the odds of reporting vaginal or pelvic pain increased and desire decreased by late perimenopause. Masturbation increased at early perimenopause but declined during postmenopause. The menopausal transition was unrelated to other outcomes. Health, psychological functioning, and importance of sex were related to all sexual function outcomes. Age, race/ethnicity, marital status, change in relationship, and vaginal dryness were also associated with sexual functioning.

CONCLUSIONS

Pain during sexual intercourse increases and sexual desire decreases over the menopausal transition. Masturbation increases during the early transition, but then declines in postmenopause. With adjustment for other factors, the menopausal transition was not independently associated with reports of the importance of sex, sexual arousal, frequency of sexual intercourse, emotional satisfaction with partner, or physical pleasure.

Correlates of sexual functioning among mid-life women

OBJECTIVE

Studies have reported a decline in sexual functioning among women undergoing the menopausal transition. Few studies, however, have examined the associations between hormones and sexual dysfunction during this time period. Therefore, the purpose of this study was to examine the associations between participant characteristics and endogenous hormones with sexual functioning in mid-life women.

METHODS

Data were analyzed from a community-based sample of 441 women aged 45-54 years who stated that they were sexually active at the time of the study. Each participant completed a survey that included questions pertaining to sexual functioning and provided a blood sample that was used to measure estrogen and androgen concentrations.

RESULTS

Among women who reported being sexually active, poorer self-reported health and the experiencing of depressive symptoms were significantly associated with not being satisfied with sexual relations after adjustment for other covariates. None of the hormones examined were significantly associated with overall sexual satisfaction. However, statistically significant associations between both total testosterone levels and the free testosterone index with satisfaction with the frequency of sexual relations were observed.

CONCLUSIONS

Our findings indicate that the experiencing of depressive symptoms and the reporting of poor overall health are important correlates of sexual dysfunction. Further, our results suggest that higher total and free testosterone levels are significantly associated with a desire for increased frequency of sexual relations among mid-life women.

Sexuality and the menopause

Sexuality is innate within all women to a greater or lesser extent, and is affected by a number of extrinsic factors that occur in the menopausal transition. Assessing hormone status is difficult as evidence exists that sex hormones may differ between ethnic groups, and that bio-assays may be insensitive at lower testosterone levels. Data are available on the prevalence of female sexual dysfunction, but results from cross-sectional studies differ from those of longitudinal studies. The original traditional models of human sexual response have been challenged, and new models have been defined which show more complex interaction between intrinsic and extrinsic factors. Definitions of sexual dysfunction have been redefined. There are a limited number of randomized, placebo-controlled trials of drugs to improve sexual function. These include sildenafil citrate, tibolone and hormone replacement therapy. Randomized controlled trials on testosterone replacement in naturally and/or surgically menopausal patients with female sexual dysfunction have been criticized for a high placebo response rate and short duration. This chapter seeks to put sexuality into perspective and to define both function and dysfunction.