Sexual Dysfunction in Postmenopausal Women
Dr. Philip M. Sarrel
Emeritus Professor of Obstetrics and Gynecology and Psychiatry
Yale University School of Medicine
New Haven, CT (USA)
Sexual dysfunction is common in postmenopausal women and the rate can be well over 80%. Pain during intercourse, decreased arousal and response, decreased frequency of sex, and loss of sexual desire are the most frequently identified problems in this population. The primary care physicians and obstetricians and gynecologists are frequently the first-line in the management of these difficulties. The healthcare providers usually have a preexisting relationship with the woman and have established a pattern of visits and trust; he/she should therefore take responsibility for the diagnosis of sexual dysfunction.
The purpose of this document is to enhance the understanding of sexual dysfunction in postmenopausal women and the development of a strategy for treatment or referral. Sexual problems in postmenopausal women are often amenable to fairly simple interventions that are (or can and should be) within the competence of primary care professionals. Providing postmenopausal women with reassuring reading materials and focusing on their specific concerns about sexual dysfunction will help reduce anxiety, as will physician suggestions keyed to the patient's individual needs.
The primary need for these patients is an initial assessment and accurate diagnosis by the primary care provider. Listening to the patient and clarifying her concerns are important for defining the nature of the problem, its severity and duration, and her motivation for treatment. Listening and clarifying serves as the cornerstone of the sexual dysfunction evaluation. The clinician must take a medical history, including inquires about diseases and/or medications that may result in sexual dysfunction. Questions about the patient's prior use of hormone therapy (HT), her current sexual relationship, and her partner's health, sexual functioning, and reactions to the patient's sexual problem are also essential components of the history. Finally, the patient should be screened for the possibility of depression and/or an anxiety disorder. In the case of severe psychiatric issues, referral or consultation may be appropriate.
Holding such a detailed conversation about sex represents optimal care, but in the real world, there are often barriers that discourage clinicians and patients. In addition, many clinicians simply do not know how to begin. Sometimes it helps to start the conversation about sexual function with a statement such as "I recently learned that a very high percentage of women after menopause have sexual difficulties. I now think that I should ask all my patients about the topic".
Evaluation Questions for Postmenopausal Women with Potential Sexual Dysfunction:
- "Do you have any questions or concerns about sex?" If the patient says, "No", we would suggest adding that, in the future, should a question or concern come up, it would be appropriate for her to discuss it with you and that you believe you can be helpful or can refer her for help.
- "Some of the most common problems after menopause are vaginal dryness, changes in sexual response, and pain with intercourse (dyspareunia). Are you bothered by any of those?"
- "Are you aware of a change in your level of interest in or desire for sexual activity?"
Physical Examination and Laboratory Studies:
Hormone depletion in postmenopausal women is associated with urogenital atrophy, which can result in dyspareunia. Atrophic changes in the vulva and the vagina can be detected during a physical examination. The tissue is thinned, frequently reddened, painful to touch, and shrunken in size. Measures of atrophy include vaginal pH and the maturation index. A healthy, mature vagina produces an acidic secretion and shows at least 20-30% superficial cells, with the remaining cells being of the intermediate type. With atrophy, the pH becomes alkaline and parabasal cells appear in the vaginal smear. Low serum estradiol and free testosterone levels are often below the normal range and may be a biological basis for the sex problem.
Women who experience dyspareunia often have multiple painful penetration experiences before seeking professional help. As a result a vaginismus reaction (involuntary perineal and perivulval muscle contraction creating a barrier to vaginal penetration) is exhibited to vaginal examination. Vaginismus is one of those conditions for which a primary care provider can be the best of diagnosticians. More traditional sex therapists, untrained in physical examination, can miss the diagnosis. Sex therapists can then carry out treatment that involves gradual desensitization to genital approach, touch, and penetration.
Providing Information and Recommending Reading:
Masters and Johnson emphasized the role of anxiety about sexual performance in the etiology of sexual dysfunction; they called this state of anxious self-observing "spectatoring". Spectatoring can be assumed to be present (usually in both partners) whenever there is a sexual dysfunction. Teaching patients about this concept helps to reduce anxiety. For prevention of sexual dysfunction, Masters and Johnson emphasized the importance of sex education in the elderly, a good general state of health, and maintaining sexual activity as a regular and continuing part of one's life. Sharing relevant information with patients can relieve worry and spectatoring and can have therapeutic effects.
Physiologic changes in sex response following menopause:
Decreased clitoral, labial, and vaginal response
Diminished Bartholin's secretion
Shorter reaction, contractions decreased, uterine pain
Rapid decrease in vaginal expansion and congestion
There are many "self-help" books available that may improve patient's understanding of sexual dysfunction. Basson model emphasizes the biological and non-biological factors that are frequently determinants of response. It also identifies emotional intimacy as a critical motivating factor for sexual activity. Spontaneous sexual desire is often absent for women and is more likely to be triggered by intimacy and deliberate attention to stimuli.
Clinicians can teach the concept that "feelings are facts". For example, a woman might be very anxious about the idea of any sexual interaction, but she may tell herself that her feeling is ridiculous and hesitate to tell her partner about the feeling. Reassuring her that feelings are not ridiculous but are important facts about her reality may help her to open up to her partner. Many women are reluctant to initiate a difficult conversation. Having a discussion in a practitioner's office can break the communications logjam. If the clinician can arrange to see the couple together, this can be extraordinarily helpful. The presence of the partner may provide additional sexual information, gives an opportunity to observe the interaction of the couple, and helps to foster communication between them.
Prescribing Hormone Therapy and/or Other Medications:
Among the most common menopause-related sex problems are vaginal dryness and dyspareunia. Vaginal atrophy and decreased vaginal blood flow secondary to estrogen deficiency appear to be the root cause of vaginal dryness and dyspareunia. Local vaginal and systemic estrogen therapies are highly effective treatment for vaginal dryness and dyspareunia. The most common problem among postmenopausal women is decreased sexual desire. Sexual problems such as low sexual desire can reduce women's sense of well-being and their quality of life. Among women participating in the National Health and Social Life Survey, low sexual desire was associated with low feelings of physical and emotional satisfaction and low general happiness.
Treatment with estrogen is frequently useful for loss of sexual desire. However, it is also clear that a proportion of women need androgens added to the estrogen treatment. Comparisons of treatments using estrogen alone with those using estrogen plus testosterone in women undergoing hysterectomy with bilateral salpingo-oopherectomy have shown a positive effect on sexual desire in the combined estrogen-plus-testosterone group. Positive effects on sexual function and satisfaction in women taking estrogen who added a transdermal testosterone patch to their treatment have recently been reported. Oral estrogens stimulate sex steroid binding globulin. Transdermal estradiol and/or the addition of an androgen show lower sex steroid binding globulin levels. Higher free steroids may explain the enhancing effects reported for estrogen plus androgen therapies. Whether considering the use of hormone therapy, the prescribing physician should be aware of the risks and benefits of such therapies.
Providing a Referral for Further Treatment:
Referral to a psychiatrist, psychologist, (clinical) social worker, nurse practitioner, marriage counselor, or sex therapist is often the best course of action for a primary health care provider. Making a good referral to the right resource, in such a way that the patient (and patient's sexual partner) will gladly follow through, requires the clinician's intelligent attention. The knowledge and information of other treatment techniques given to patients are also helpful. Some clinicians know that they are not in a good position to offer patients help with a sexual problem. Providers who cannot or who choose not to try to help treat sexual problems (except perhaps to prescribe HT) should be prepared to make intelligent referrals. To find a sex therapist in the United States, consult the American Association of Sex Educators, Counselors and Therapists (AASECT) and/or the Society for Sex Therapy and Research. The AASECT in one of the several national organizations which lists qualified sex therapists and kind of sex therapy provided.
Many clinicians have never made a referral to a sex therapist. Obviously, clinicians must be able in inform couples of what to expect, and couples must give permission for providers to contact sex therapists on their behalf. Following are some basic facts about sex therapy that may be helpful to both clinicians and couples:
- Sex therapy works with and focuses on the couple -- with respect to their communication in and out of bed. Individuals may be seen in sex therapy. However, it is usually best for couples to go for sex therapy when there is an existing relationship because partners can be an important part of the problem (often without realizing it).
- Sex therapy is time-limited and structured.
- The starting point in sex therapy is to gain an understanding of each individual (ie, how the individual's life history affects the way he or she relates emotionally and sexually).
- Medical history and physical findings are crucial dimensions of sex therapy.
- Education about sexual function is also an essential component of sex therapy.
- Couples will be assigned behavioral "homework", which should enable them to make a new start in how they relate emotionally and sexually.
- There is no sex between patient(s) and therapist or in the presence of the therapist.
Sexual dysfunction is a very common problem and a frequent source of distress among postmenopausal women that may often be best detected and managed by the primary care provider. Numerous biological, psychological, and relationship factors can contribute to sexual problems in these women, requiring careful listening and inquiry by clinicians during evaluation. Identification of specific types of sexual dysfunction and their impact on patients and partners is an important aspect of the medical history. Physical examination may be particularly helpful in diagnosing atrophic vaginal changes, which frequently result in dyspareunia after menopause, and secondary vaginismus. Patient education about sexual function and pathology, provided during in-office discussions and via recommended at-home reading, can help to reduce anxiety and enhance communication between partners and patients and clinicians.
Clinicians may make a number of simple suggestions that can have a rapid positive effect on patient's sexual dysfunction, including most notably, the avoidance of painful sex (dyspareunia). Changes in sex hormones can contribute to common menopausal sexual problems, including dyspareunia and low sexual desire. Administration of estrogen alone often is effective in improving these problems, but the addition of testosterone may be beneficial in some women. Knowing when to refer patients for specialist care is an essential aspect of managing sexual disorders. Specialized care is recommended for patients with serious psychiatric disorders and long-standing relationship or sexual issues, as well as for those who do not improve with treatment.
Suggested Reading: Philip M. Sarrel, MD. Sexual Dysfunction: Treat or Refer. Obstet Gynecol. Vol. 106, No. 4, October 2005, pp 834-839. The American College of Obstetricians and Gynecologists publication; published by Lippincott Williams & Wilkins.
Gratitude is express to Dr. Philip M. Sarrel for sharing his work, research and wisdom with Women's Health & Education Center (WHEC). It is indeed an honor to have his work on WomensHealthSection.com. His research and insights in reproductive health and aging, has helped us all to have better understanding of these topics and has helped us tremendously to provide good care to our patients. We at WHEC are looking forward to work with him for a long time to come. Thanks again Dr. Sarrel.
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