Longitudinal Changes in Sexual Functioning as Women Transition Through Menopause: Results From the Study of Women's Health Across the Nation

Nancy E. Avis, PhD; Sarah Brockwell, PhD; John F. Randolph, Jr, MD; Shunhua Shen, MS; Virginia S. Cain, PhD; Marcia Ory, PhD; Gail A. Greendale, MD


Menopause. 2009;16(3):442-452. 

In This Article


Objective: Sexual functioning is an important component of women's lives. The extent to which the menopausal transition is associated with decreased sexual functioning remains inconclusive. This study seeks to determine if advancing through the menopausal transition is associated with changes in sexual functioning.
Methods: This was a prospective, longitudinal cohort study of women aged 42 to 52 years at baseline recruited at seven US sites (N = 3,302) in the Study of Women's Health Across the Nation (SWAN). Cohort-eligible women had an intact uterus, had at least one ovary, were not currently using exogenous hormones, were either premenopausal or early perimenopausal, and self-identified as one of the study's designated racial/ethnic groups. Data from the baseline interview and six annual follow-up visits are reported. Outcomes are self-reported ratings of importance of sex; frequency of sexual desire, arousal, masturbation, sexual intercourse, and pain during intercourse; and degree of emotional satisfaction and physical pleasure.
Results: With adjustment for baseline age, chronological aging, and relevant social, health, and psychological parameters, the odds of reporting vaginal or pelvic pain increased and desire decreased by late perimenopause. Masturbation increased at early perimenopause but declined during postmenopause. The menopausal transition was unrelated to other outcomes. Health, psychological functioning, and importance of sex were related to all sexual function outcomes. Age, race/ethnicity, marital status, change in relationship, and vaginal dryness were also associated with sexual functioning.
Conclusions: Pain during sexual intercourse increases and sexual desire decreases over the menopausal transition. Masturbation increases during the early transition, but then declines in postmenopause. With adjustment for other factors, the menopausal transition was not independently associated with reports of the importance of sex, sexual arousal, frequency of sexual intercourse, emotional satisfaction with partner, or physical pleasure.


Sexual functioning is an important component of women's lives and has increasingly received public health, pharmaceutical, and medical attention.[1] More than 75% of the middle-aged women in the Study of Women's Health Across the Nation (SWAN) reported that sex was moderately to extremely important.[2] Sexual functioning, however, declines with age,[1,3,4,5,6,7,8] leading to much debate on the contribution of menopause to sexual activity and functioning among women.

The menopausal transition is a gradual change from premenopause to postmenopause, which is defined retrospectively after 12 months of amenorrhea. Some evidence suggests that sexual functioning declines over the menopausal transition, yet whether this decline is due to menopause, aging, or other variables remains inconclusive.[3,4,9,10,11,12] Understanding factors that affect sexual functioning can help clinicians counsel women. Most studies in this area are cross-sectional, not large enough to separate the effects of menopause from chronological aging, and/or do not include relevant covariates.

Relationship, psychosocial, and health factors are often reported as more important determinants of sexual function than ovarian function. Primary factors associated with a woman's sexual function include the availability of a partner,[10,13,14,15] relationship quality,[9,16,17,18,19] psychological function,[1,10,19,20,21,22] health,[13,20,23] and race/ethnicity.[16,24]

Longitudinal data from SWAN provide the opportunity to disentangle the role of menopause from chronological aging in sexual functioning and activity among a multiethnic sample while also examining concurrent social, health, and psychological parameters. With 6 years of follow-up data, this large cohort of 3,302 women at baseline provides the opportunity to examine changes in sexual functioning as women progress through the menopausal transition. The primary research question was as follows: Independent of chronological aging and time, is advancing through the menopausal transition associated with a decline in sexual functioning? Secondarily, we were interested in (1) whether menopausal symptoms (hot flashes, night sweats, vaginal dryness) contributed to a dimunition in sexual functioning over and above menopause status and (2) the relative contribution of menopause and other health, social, psychological, and relationship factors to sexual funtioning.