Help your older patients maintain healthy sexuality
By Penelope Morrison Bosarge
RNC, CRNP, MSN
Women’s Health Nurse Practitioner
Teaching Faculty, Graduate Programs
University of Alabama School of Nursing
Birmingham
There is conflicting research concerning the effect of menopause on sexual functioning. Some data suggest aging alone is responsible for decreased desire and sexual activity, while others find the changes associated with menopause are responsible for the difficulties. Another predictor of sexual difficulties in some women was the anticipation of such problems.1,2
Healthy psychosexual functioning during menopause has many facets encompassing a complex interaction of anatomical, physiological, and psychological factors. Triggering this cascade of events is decreased estrogen.
Many women accept sexual difficulties as the unfortunate consequences of aging and don’t realize that menopause plays a role. Thus, they never share their concerns with their health care provider. This column will describe changes that may affect a woman’s ability to enjoy a healthy sexual life as she ages and suggestions that you, as a clinician, can make for successful management.
Physical changes impact sexual function
Anatomical changes include a loss of pelvic support and vaginal strength. The vagina may shorten with constriction in the upper one-third. These changes may be significant enough to interfere with the enjoyment of sexual activity or may make intercourse difficult, if not impossible.
Urethral atrophy along with loss of pelvic support may lead to loss of urinary continence. Vulvar irritation may result and cause pain when intercourse is attempted. Pelvic organs may prolapse when vaginal elasticity and ligament strength decline, which allows gravity to take its toll over time.3
Vaginal atrophy can cause dryness, resulting in irritation, burning, and itching with subsequent bleeding and dyparunia. Vaginal lubrication is decreased in volume and viscosity. Up to 60% of women require increased time and amount of stimulation to start lubricating and to produce adequate quantities.
Lubrication is often considered the sign of sexual arousal. If not present, the woman or partner may feel she is inadequate to perform sexually. When penetration is attempted, pain and/or burning may occur, which often remains after intercourse is complete.4
Body shape will change, which may be distressing. The changes, which seem to occur overnight, are affected by gravity and loss of elasticity of skin and tissues. Physical appearance affects our self-esteem, and thus our sexuality. These changes, if perceived as unattractive, may alter the positive image of a woman as a sexual person.
Don’t overlook role of health problems
Health problems such as acute and chronic illness may play a large role in how we perform as sexual people. For example, the pain of arthritis or its effects on flexibility may be a factor to consider. Psychological status affects sexuality negatively when depression or other emotional problems are present. Recognition and treatment of these situations may be the solution for many women.
Years that are supposed to be happy and carefree shouldn’t be marred by serious clinical pathology affecting sexual experiences. Recent awareness of the problems and willingness on the part of patients and health care providers to discuss the subject openly have led to prevention strategies and successful treatment.
Any treatment should take into consideration the woman’s attitudes toward sex. Does she perceive there is a problem? She may see sex as a marital duty that she can happily discontinue at menopause. However, many women continue to have powerful sexual feelings into advancing age but are limited by a disinterested partner or no partner at all.
A concerned health care provider, who has been made aware of the patient’s needs, can help her make choices about treatments. Prevention is always the best treatment. One convenient and successful program of prevention includes hormone therapy.
Some researchers claim that testosterone and its derivatives show a convincing beneficial effect, with increased sexual satisfaction, frequency of orgasm, and sexual arousal.5
(Editor’s note: The use of androgens in post-menopausal women remains controversial. Contraceptive Technology Update readers may want to consult Clinical Gynecologic Endocrinology and Infertility to broaden their knowledge on the subject.6)
Estrogen by any route is helpful in preserving or restoring vaginal mucosal thickness and secretions and preventing the negative anatomical changes. Promotion of positive attitudes to aging and menopause, stress reduction, and healthy lifestyles will improve a sense of well being, which will translate into improved sexual functioning.
Age happens! Our aging bodies can be compared to an older home, where things seem to go wrong all at once. Suddenly there are creaky doors, dripping faucets, running toilets, and sticking doorbells. Proper maintenance of the body, just as with a home, will prevent changes from being so problematic and costly.
References
1. Dennerstein L, Dudley E, Hopper J, et al. Sexuality, hormones, and the menopausal transition. Maturitas 1997; 25:83-93.
2. McCraw, RK. Psychosexual changes associated with the perimenopausal period. J Nurse Midwifery 1991; 36:17-24.
3. Bachmann GA. Influence of menopause on sexuality. Int J Fertil Menopausal Studies. 1995; 40 Suppl 1:16-22.
4. Freeman SB., Menopause without HRT: complementary therapies. Contemporary Nurse Practitioner 1995; 1(1).
5. Palacios S, Menendez C, Jurado AR, et al. Changes in sex behavior after menopause: effects of Tibolone. Maturitas 1995; 22:155-161.
6. Speroff L, Glass RH, Kase NG. Clinical Gynecologic Endocrinology and Infertility. 4th ed. Baltimore, MD: Williams and Wilkins; 1989, pp. 623-624.
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