Sexual health in older women

Sexual activity declines with age, both men and women continue to engage in in vaginal intercourse, oral sex, and masturbation even in the eighth and ninth decades of life.



Sexual function in women is affected by somatic, psychosocial, and neurobiological factors.



Sexual dysfunction relates to desire, arousal, orgasm, and pain. 



Libido is influenced by physical and psychological health of the patient, relationship concerns, past sexual experiences, and personal beliefs about sexual activity. 



Sexual arousal is a neurovascular response to desire.



Sexual arousal is characterized by vascular congestion in the breasts, clitoris, and vagina.



Orgasm, which may follow arousal, is marked by sexual release followed by rhythmic contractions in the pelvic musculature. 



Pain is related to penetrative sexual activity may occur with initial or deep penetration.



 The aging process, generally leads to an increased prevalence of sexual complaints, most commonly decreased desire for sexual activities. 



Decreased estrogen levels after menopause lead to the genitourinary syndrome of menopause, previously known as vulvovaginal atrophy. 



The genitourinary syndrome of menopause, occurs in approximately 50% of postmenopausal women.



The genitourinary syndrome of menopause is characterized by an alteration in the vaginal microbiome and architecture of the vagina and vulva; the vaginal dryness and pain with penetration results.



With age there is a decrease in genital blood flow and diminished genital sensation, decreased pelvic floor tone, all of which may contribute to delayed or less intense orgasm.



Decreasing levels of estrogen and androgens with aging may also contribute to low desire, difficulty with arousal, and impaired orgasm.



Distress related to sexual function is the hallmark of female sexual dysfunction. 



Prevalence of Female Sexual Problems Associated With Distress and Determinants of Treatment Seeking (PRESIDE) study of 31,000 women aged 18 to 102 years: sexual health concerns increases with age



Sexual complaints were reported by 27% of women aged 18 to 44 years, by 44.6% aged 45 to 64 years, and by 80.1% aged 65 years or older. 



Distress related to sexual problems was the highest (14.8%) in the middle-age group (45 to 64 years old) and the lowest (8.9%) in women 65 years or older.



Women who rate their health as poor are less likely to be sexually active, and women with poor health who do remain sexually active often report sexual problems.



Conditions that affect sexual function: 



Diabetes mellitus-Diminished genital vascular supply,  deceased arousal and orgasm.



Cardiovascular disease Diminished genital vascular supply,  decreased arousal and orgasm.



Peripheral neuropathy Impact on small nerve fibers in vulva and anterior vagina



Decreased genital sensation and impaired arousal.



Neuromuscular disorders/spinal cord/multiple sclerosis



Direct effect on vulvar/vaginal innervation



Associated pain



Vaginal stenosis/dyspareunia



Decreased desire, genital sensation, arousal, and orgasm



Musculoskeletal conditions



Pelvic organ prolapse



Urinary incontinence



Surgical interventions: hysterectomy/oophorectomy



Loss of urine during intercourse



Loss of systemic estrogen: Deceased desire and genital sensation, arousal and orgasm


a GSM = genitourinary syndrome of menopause.



Medications can cause or worsen pre-existent sexual health problems: Selective serotonin reuptake inhibitors induce sexual dysfunction in 30% to 70% of women and lead to complaints in the domains of sexual desire, arousal, and orgasm.



Antihistamine and anticholinergic medications may impede arousal, and common cardiovascular drugs such as β-blockers may negatively affect sexual desire.



Alcohol intoxication impairs sexual response.



Patients are often reluctant to discuss sexual health concerns with their primary care providers; survey of older adults 96% of women and 92% of men who had at least one sexual problem had not sought help.



Dyspareunia and vaginal dryness are a common problem often occurring simultaneously in 80% of postmenopausal women.



Vaginal lubricants and moisturizers may suffice for moderate to severe symptoms in appropriately selected patients, and hormonal treatments may include vaginal estrogen or dehydroepiandrosterone (DHEA) and oral ospemifene.



In comparative studies, both intravaginal estrogen twice weekly and DHEA (6.25 mg) suppository nightly improved vaginal dryness and dyspareunia. 



Currently, no approved medications are available to enhance female sexual function of desire, arousal, or orgasm in postmenopausal women. 



((Flibanserin)) has been found to improve hypoactive sexual desire disorder in postmenopausal women, it is approved for this indication in premenopausal women only.



The use of a personal vibrator or pillows for positioning during sexual activity may enhance sexual function. 



For those with more complex sexual health issues a multidisciplinary approach including psychotherapy or sex therapy may be helpful.



Social determinants of sexual function include women residing in an assisted-living facilities,  nursing homes but still require  tenderness, sexual contact, and emotional closeness, but the lack of privacy, dealing with attitudes of staff, family, lack of a sexual partner, and physical limitations are some of the identified barriers to healthy sexual expression.











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