Spotlight on Aging: Sexual Dysfunction in Older Women

Older women may develop sexual problems for various reasons.

Age-related changes, particularly those due to menopause, can make women more likely to experience sexual dysfunction. Also, medical conditions that can interfere with sexual function, such as diabetes, atherosclerosis, urinary tract infections, and arthritis, become more common as women age. However, these changes need not end sexual activity and pleasure, and not all sexual dysfunction in older women is caused by age-related changes.

In older women, as in younger women, lack of interest in sex is common. This may be seen as a problem by a woman or not, depending on whether her lack of libido causes her distress.

Another reason older women give up on sex is when a partner has sexual function problems or when they do not have a partner. Or they may be worried about the general health of their partner.

After menopause, less estrogen is produced, and this may result in changes in the vaginal tissues called genitourinary syndrome of menopause, which includes the following:

• With aging, blood flow to the vagina is reduced, causing it to become shorter, narrower, and drier. The tissues around the vaginal opening (labia) and the walls of the vagina become less elastic (ability to stretch) and thinner (called vulvovaginal atrophy). Vaginal secretions are reduced, providing less lubrication during sexual intercourse. Both of these changes can cause pain during sexual activity that involves penetration.

• The pH of the vagina changes (it is normally acidic), making the genitals more likely to become irritated and infected. Tissues can also become inflamed and irritated.

• Lack of estrogen may contribute to age-related weakening of muscles and other supportive tissues in the pelvis, sometimes allowing a pelvic organ (bladder, intestine, uterus, or rectum) to bulge into the vagina (called pelvic organ prolapse). Also, urine may leak involuntarily. Women may feel embarrassed about these issues or worry that they will interfere with sex.

After menopause, some women experience a decrease in sexual interest, arousal, or ability to have an orgasm. The hormonal reasons for this are not clearly understood. When menopause occurs, blood levels of the hormones estrogen and progesterone decrease markedly. However, women's testosterone levels are usually highest in their 20s and then decrease slowly with age. There is no abrupt change with menopause. So, it is unclear what roletestosterone plays in women's sexual function.

Other problems may interfere with sexual function. For example, some women may experience negative changes in body image or their sense of themselves as a sexual person as they age. This may also occur if they have illness, physical limitations, or surgeries or other treatments that result in change in their bodies. They may have cultural views that sexual desire and fantasy are improper or shameful at an older age.

Older women should not assume that sexual dysfunction is normal for older age. If they have sexual function concerns, they should talk to their doctor. In many cases, treating a health condition (including depression), stopping or substituting a medication, learning more about sexual function, or talking to a health care professional or counselor can help.

For vaginal dryness or painful sex due to menopause, treatment with vaginal lubricants and moisturizers is used first. If this does not help, many women can be treated with vaginal hormone therapy, including low-dose estrogen (as a cream, tablet, or ring) or dehydroepiandrosterone (DHEA, as a suppository). Estrogen can also be taken by mouth or applied to the skin in a patch or gel, but these forms of estrogen affect the whole body and are usually only used if a woman also has other symptoms of menopause (such as hot flashes) and if hormone therapy does not have too high a risk of complications for them, depending on health status and age. Estrogen has potential risks (including blood clots and a slightly increased risk of breast cancer) as well as benefits, so women should talk to their doctor about its risks and benefits before starting to take it.