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Variables Affecting Female Sexual Function - Effects of Perimenopause/Menopause on Female Sexual Response

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Effects of Perimenopause/Menopause on Female Sexual Response

Although menopause symptoms can indirectly affect sexual responsitivity (see Table 4), as with aging, menopause does not represent an end of sex.(5) Declining estrogen and testosterone levels may be associated with a flagging sex drive, but in light of Basson's recent model of the sexual response pattern, this may not be as important an occurrence as once thought.(14) If desire is not the motivating force for sexual activity for many women, as Basson contends, then the loss of spontaneous desire may not have very much impact on a woman's sexual life at all if her partner is still interested in engaging in sex.(2,3)


TABLE 4.Possible Changes in Sexual Function at Menopause

  • Decline in desire
  • Diminished sexual response
  • Vaginal dryness and dyspareunia
  • Decreased sexual activity
  • Dysfunctional male partner

Recent studies suggest that the hormonal changes that occur during menopause have less of an effect on a woman's sexual life and response than do her feelings about her partner, whether her partner has sexual problems, and her overall feelings of well-being.(4,5)

For instance, analysis of data from 200 premenopausal, perimenopausal, and postmenopausal women with an average age of 54 from the Massachusetts Women's Health Study II (MWHS II) showed that menopause status had less of an impact on sexual functioning than health, marital status, mental health, or smoking.(4) Satisfaction with their sex life, frequency of sexual intercourse, and pain during intercourse didn't vary by women's menopausal status. Postmenopausal women did self-report significantly less sexual desire than premenopausal women (p<0.05) and were more likely to agree that interest in sexual activity declines with age. Perimenopausal and postmenopausal women also reported feeling less aroused compared with when they were in their 40s than premenopausal women (p<0.05). Interestingly, the presence of vasomotor symptoms was not related to any aspect of sexual functioning.

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Declining Estrogen Levels

The loss of ovarian production of estradiol at menopause can result in vaginal dryness and urogenital atrophy, which can affect sexuality.(15) In the MWHS II, vaginal dryness was associated with dyspareunia or pain after intercourse (OR=3.86) and difficulty experiencing orgasm (OR=2.51).(4) On the other hand, a study by Van Lunsen and Laan found that sexual symptoms after menopause might be related more to psychosocial issues than to age- and menopause-induced changes in the genitals.(16) These authors suggest that some postmenopausal women who complain of vaginal dryness and dyspareunia may be having sexual intercourse while unaroused, perhaps a longstanding practice (linked to their unawareness of genital vasocongestion and lubrication) before menopause. They may not have noticed the dryness and pain because their estrogen production was high enough that it masked a lack of lubrication.

Moodiness or depression associated with the hormonal changes of menopause also can lead to loss of interest in sex, and changes in body configuration can be inhibiting.(15)

Declining Testosterone Levels

By age 50, testosterone levels are reduced by half in women compared with age 20.(16,17) As women enter menopause, the levels remain stable or may even increase slightly.(18) In women undergoing removal of the ovaries (oophorectomy), testosterone levels also drop by 50 percent.(18)

Effects of Disease on Female Sexual Response

Although psychosocial factors are the focus of much discussion today in the pathogenesis of sexual disorders, physical factors remain important and cannot be dismissed (see Table 5). A variety of medical conditions can directly or indirectly affect female sexual functioning and satisfaction. For instance, through lack of adequate blood flow, a vascular disease such as hypertension or diabetes might inhibit the ability to become aroused.(21) Depression, anxiety, and conditions such as cancer, lung disease, and arthritis that cause a lack of physical strength, agility, energy, or chronic pain also can affect sexual functioning and interest.(3,14)


TABLE 5. Medical Conditions That Can Affect Female Sexuality(21,26)

Neurologic Disorders

  • Head injury
  • Multiple sclerosis
  • Psychomotor epilepsy
  • Spinal cord injury
  • Stroke

Vascular Disorders

  • Hypertension and other cardiovascular diseases
  • Leukemia
  • Sickle-cell disease

Endocrine Disorders

  • Diabetes
  • Hepatitis
  • Kidney disease

Debilitating Diseases

  • Cancer
  • Degenerative disease
  • Lung disease

Psychiatric Disorders

  • Anxiety
  • Depression

Voiding Disorders

  • Overactive bladder
  • Stress urinary incontinence

In the MWHS II, depression was negatively associated with sexual satisfaction and frequency, and psychological symptoms were related to lower libido.(4) Hartmann et al. also showed that women who suffer from depression are more likely to indicate low sexual desire than those without depression. (5)

Procedures such as hysterectomy and mastectomy also may have a physical, as well as an emotional, impact on sexuality. Removing or altering female reproductive organs may lead to discomfort during sexual encounters (e.g., dyspareunia) and leave women feeling less feminine, sexual, and desirable.(22) In recent years, however, studies have suggested that elective hysterectomy may actually result in an improvement in rather than a deterioration of sexual functioning.(23,24) Oophorectomy, on the other hand, leads to a deterioration of functioning, at least initially, because of the sudden cessation of sex hormone production and the onset of premature menopause.(25)