Sexuality in the Aging Couple, Part I: The Aging Woman

Irwin W. Kuzmarov, MD, FRCSC; Jerald Bain, BScPhm, MD, MSc, FRCPC, CertEndo, BA

Disclosures

Geriatrics and Aging. 2008;11(10):589-594. 

In This Article

Sexual Function and Dysfunction in Women

Female sexual arousal is a topic of popular and social interest but for many years physicians have paid little attention to this subject. In the era that saw new pharmaceutical agents developed to treat erectile dysfunction, male sexual dysfunction captured the major proportion of attention in the world of sexual medicine. Over the last decade, however, female sexual function and dysfunction have emerged as areas of increasing study and therapy.[7,8,9,10]

Masters and Johnson described the female sexual response as consisting of three phases: arousal, orgasm, and resolution.[11] The American Psychiatric Association has classified the phases of the sexual response cycle into four related but distinct phases: libido (desire), arousal, orgasm, and resolution.[12] This paradigm had already been discussed by Helen Singer Kaplan, founder of the first clinic for sexual disorders established at a medical school in the U.S.[13] Although this model seemed to reflect the male sexual response reasonably well, it appeared not to be universally applicable to the female sexual response cycle (Figure 1).

Figure 1.

The female sexual response cycle

During sexual arousal, there is vasocongestion of the genitals; the clitoris and labia minora become engorged with blood and vaginal and clitoral length and diameter increase. However, there are physiologic and pathologic changes in women as they age related to menopause that lead to changes in the vagina, ovary, uterus, vulva, breasts, and bladder.

There are changes in the female sexual response cycle, as women age, that affect their reaction to sexual intimacy.[14] Libido is maintained until quite late in the aging process.[15] With aging, there is delayed or diminished vaginal lubrication and vasocongestion, diminished frequency of contraction of the vagina, and decreased frequency of orgasm. It is not completely clear how the decline in hormonal levels of estrogen, and progesterone and the role of testosterone relate to female sexual functioning as aging progresses. It is recognized that estrogen replacement therapy will restore vaginal epithelial function, increase vaginal flow, and increase the sense of well-being but it is not certain it will improve sexual function.[16] In addition, concomitant medical conditions as well as medication can affect the various phases of sexual response and exacerbate relationship issues.

More clearly understanding the female sexual response has required a new approach, a new paradigm, and a new way to delineate its features if progress in this area was to be fully realized. Basson emphasized that the new schemata had to take into consideration "that women's sexual response more commonly stems from intimacy needs rather than a need for physical sexual arousal."[8] Basson and others (e.g., Leiblum[17]) stressed that the female response was only partially enhanced by genital vasocongestion. There are more cerebral and cognitive issues at play such that "sexual desire then is a responsive rather than a spontaneous event." For women, therefore, the sexual response may not be primarily the specific thinking of sexual thoughts but other factors such as intimacy, bonding, commitment, love, affection, acceptance, etc., all of which may enter the sexual response equation.[8] Included in this new paradigm is the fact that orgasm is not always essential for a satisfying sexual encounter.

The subjective experience of sexual arousal in women is not necessarily well correlated with genital vasocongestion.[18] The role of estrogen in sexual arousal remains unclear. What is more certain is the multiplicity of factors that can disturb sexual desire and sexual responsiveness.[7] These include a diverse array of physical, psychological, or therapeutic factors such as mood disorders, relationship issues, adverse sexual experiences, history of medical illness, estrogenic substances, antidepressants, or physical illness. A history of physical, sexual, or emotional abuse approximately doubles the chances of developing female sexual dysfunction.[19] Vascular disease is far less an issue in female sexual function than it is in men.

Categories of sexual dysfunction in women have been well-summarized and described by Basson[20] and are presented in Table 2 . Management of sexual arousal is guided by the diagnostic category into which the reported problem falls.

Age-related changes in sexual responsiveness and any incidence of sexual dysfunction in the female will precipitate adjustments in the couple's sexual relationship, and must be assimilated with the changes going on in the male partner. Further adjustments may concern the necessity of coping with concomitant medical conditions or psychosocial events that may be going on in the couple's lives (retirement, musculoskeletal disorders, cardiovascular disease, etc.). A significant proportion of the aging population is able to maintain a healthy sex life, adjusting to these changes and adapting their sexual interactions to accommodate these limitations.

Despite the fact that older women report more sexual difficulties than younger women, more than half of them report being satisfied with their overall sexual relationship, implying that sexual function may not be the only factor at play in overall satisfaction.[16] In a study of sexuality and health among older adults in the U.S., it was shown that about half of women and half of the men who were sexually active reported at least one bothersome sexual problem.[21] This attests to the importance of sexual activity in the aging population and the adaptive process.

A decline in sexual interest and desire is frequently reported to be more severe in aging woman than aging men.[1] In addition, in studies that compare the incidence of intercourse in men and women, men are more sexually active than women.[22] Sexual dysfunction appears to have a higher prevalence among women than men: for example, Laumann et al. found that 43% of women as compared to 32% of men complained of sexual dysfunction.[23] The most prevalent disorder in women is hypoactive sexual desire (Figure 2), to which many factors can contribute. These discrepancies, coupled with the advent of PDE-5 therapy, has led to certain adjustments in the sexual interaction of some couples.

As more attention turned to female sexual concerns and more studies revealed the high incidence of reduced libido among women (approximately one-third of American women state they have a low libido)[23,24] there arose an increasing interest in the possible role that testosterone therapy might have in redressing loss of libido. There was the widespread belief that since testosterone has libido-enhancing properties, it might potentiate waning sexual interest among women, at least among women who for physiological or pathological reasons had a low testosterone-producing capacity.

Figure 2.

Incidence of sexual dysfunction in women

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