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Section 15
Sexual Function and the Menopausal Woman

Question 15 | Test | Table of Contents

Sexual behavior involves a complex interplay of biochemical, neurophysiological, and cognitive processes (Bancroft, 1988). Age, and the availability and presence of a partner, further contribute to the multivariate nature of human sexuality (Segraves & Segraves, 1995). The influence of menopause on sexual function has received much attention in the research; however, the influence of age and partner presence is often not considered. Those studies that have considered the influence of age on the sexual function of the menopausal woman are inconsistent in their findings. McCoy (1998), in a recent study, also suggested that partner's sexual interest and partner's sexual function within the relationship need to be included as variables which may influence a woman's sexual function around the time she may be going through midlife and menopause. While some studies have included investigation of physiological changes related to sexual arousal which may be associated with menopause, few report on desire and frequency of intercourse. In particular, there is little understanding of each of these factors within the context of age and the sexual relationship between a menopausal woman and her partner. The present study investigated whether age and partner's sexual function were important factors to take into consideration in the understanding of the sexual function of the menopausal woman.

At menopause a decline in estrogen levels results in decreased vaginal blood flow and decrease in vaginal lubrication and vaginal elasticity. Many studies confirm the link between decreased levels of estrogen and an increase in pain with intercourse (Nachtigall, 1994; Nathorst-Boos, Wiklund, Mattsson, Sandin, & Schoultz, 1993; Riley, 1991), as well as increased urinary tract infections in menopausal women (Raz & Stature, 1993; Van der Linden et al., 1993). During sexual stimulation in menopausal women there is some evidence that arousal, indicated by vaginal lubrication and engorgement of the genitals, is less than premenopausal levels (Leiblum, Bachnann, Kimmann, Colburn, & Swartzman, 1983; Morrell, Dixen, Carter, & Davidson, 1984; Semmens & Wagner, 1982). Painful intercourse has been found to reduce frequency of coitus in a large community-based sample of menopausal women (Dennerstein, Smith, Morse, & Burger, 1994).

Changes in sexual arousal have been linked to physiological consequences of menopause, particularly in clinic samples; however, the impact on sexual desire is less clearly understood. While Bancroft (1984) suggested that no clear demonstration of changes to sexual desire (either positive or negative) could be linked to hormonal changes associated with menopause, Channon and Ballinger (1986) found that 271 perimenopausal women who came to a menopause clinic bad reduced desire, enjoyment, and frequency of orgasm. These researchers suggested that vaginal symptoms such as dryness and soreness resulted in decreased desire along with factors such as age and partner's age. The reason why there are conflicting reports by menopausal women of reduced desire are likely to be complex, and require further investigation.

Since menopausal women are usually entering the decade of their 50s, it would also appear important to consider the influence of age on the sexual functioning of the menopausal woman. Past research has reported mixed findings regarding the influence of age on the sexual function of the menopausal woman. Some studies have concluded age is a more appropriate predictor of sexual satisfaction than menopause, while others fail to account for menopausal stares or include small numbers of menopausal women.

In some studies older age was found to significantly predict a decrease in the enjoyment of sexual behaviors in premenopausal and perimenopausal women (Mansfield, Voda, & Koch, 1995). Other studies have also found that age group influenced reports of sexual frequency. In a small group of menopausal women (n = 36), Hawton, Gath, and Day (1994) found that women enjoyed their sexual relationships less as they got older, preferring infrequent sexual activity. In a large community study, Hallstrom and Samuelsson (1990) found that increasing age, along with reports of anxiety neurosis and use of psychotropic medication, decreased sexual desire. However, menopausal status was not reported, so it is not clear if menopausal status contributed to reports of decreased sexual desire. Osborn, Hawton, and Gath (1988) also suggested that age was related to reports of sexual dysfunction significantly more than menopausal status. Osborn et al. found 49% of women aged over 50 years had one or more sexual dysfunctions, while 21% of women under 50 years had one or more sexual dysfunctions.

Interestingly Dennerstein, Dudley, Hopper, and Burger (1997) found that sexual function was affected only minimally by age, and not at all by menopausal status. In a cross-sectional study of 201 women from a community-based sample (all of whom had partners), age was found to account for levels of "sexual responsivity"; however, no other factors influenced measures of sexual function. Menopausal status did not predict sexual frequency, libido, feelings for the partner, partner problems, or vaginal dryness.

In contrast to the above findings, a small number of researchers have found that sexual interest was influenced more by menopausal status than by age (e.g., Hallstrom, 1977). After controlling for age, Hunter (1990) found in her sample of 474 community-sampled women that sexual interest decreased from pre- to peri- to postmenopause. However, Hunter argued that factors such as ill health (possibly an age-related factor) and stress should also be taken into consideration when investigating sexual function.

Thus, research on the influence of age on sexual response among menopausal women has resulted in inconsistent findings, even in community-based samples. Part of the problem may be that some studies have not included postmenopausal women (Mansfield et al., 1995), or that women have not spent a long time in menopause (Hawton et al., 1994; Osborn et al., 1988). The past research does highlight the importance of accounting for both menopausal stage and age in the understanding of the sexual function of the menopausal woman.

Exploration of the sexual function of the menopausal woman's partner may also enhance our understanding of sexual function at the menopause. Past research has found that sexual desire was highly correlated with partner availability and low frequency of intercourse, but not with menopausal status (Koster & Garde, 1993). Dennerstein et al. (1994) also found that some women indicated that reduced sexual desire was a result of poor partner health and partner disinterest. However, the involvement of the partner was not explored further in this study, and women who suggested their partner influenced sexual interest were excluded from some analyses.

Few researchers have reported on the effects of decreased arousal in the woman within the context of the sexual relationship with a partner. In a rare study of arousal in 50 married couples who sought help specifically for sexual dysfunction and not for menopause, Sarrel (1982) found that male partners felt inadequate when their wives did not become easily aroused (due to reduced lubrication from hormonal changes), and also feared hurting them during sexual intercourse. Twenty-eight of the male partners had experienced erectile difficulties either just before their partner's menopause or within a few years of menopause. Even though more than half of the male partners experienced sexual difficulties around the time of their partner's menopause, these findings have not been followed up in later studies.

Larson, Collins, and Landgren (1997) argued that while vaginal dryness may be partly associated with estrogen levels, vaginal dryness "can be explained by other factors such as relationship with a partner" (p. 103). Empirical research is needed to further investigate these suggestions.
Interestingly, few studies have considered sexual frequency, the menopausal woman, and her partner, in a very early study, George and Weiler (1981) found that marital adjustment and the male partner's role as initiator of sexual behavior was an important factor when considering sexual function and mid-life. Cessation of sexual activity was often due to the attitude and the ability of the male to perform sexually. In their small study of women who were recently postmenopausal, Hawton et al. (1994) suggested that a decrease in sexual frequency resulted from a decline in marital adjustment, partner interest, and partner availability.

Personal Reflection Exercise #8
The preceding section contained information about sexual function and the menopausal woman.  Write three case study examples regarding how you might use the content of this section in your practice.

QUESTION 15
In a small study of women who were recently postmenopausal, what three factors were suggested to decrease sexual frequency? To select and enter your answer go to Test.