Female Sexual Function and the Pelvic Floor

Sarit O. Aschkenazi;   Roger P. Goldberg


Expert Rev of Obstet Gynecol. 2009;4(2):165-178. 

In This Article

Female Sexual Function, Aging & Menopause

Owing to improvements in life expectancy for women in the USA women will spend approximately a third of their lives in postmenopause[43]. Several population-based surveys from different parts of the world have advanced our understanding of the relationship between aging, menopause and sexuality. Summarizing the results, it seems that sexual interest slowly diminishes with advancing age, whereas the prevalence of sexual dysfunction, particularly HSDD and arousal disorders, increases[44,45]. The literature indicates that there is a greater variability of virtually all sexual parameters as a woman ages, indicating that the sexuality of older women compared with younger women is more dependent on basic conditions such as general well-being, physical and mental health, quality of relationship or life situation[46]. These factors determine whether a woman can retain her sexual interest and pleasure in sexual activity. The results also point out that sexual interest depends on past sexual experience and on the quality and meaning sexuality had in younger years. Among older women, the discrepancy between sexual interest and actual sexual activity is often greater than in younger women, mostly because of lack of an adequate partner. In other cases, the cessation of sexual activity can be an expression of emotional problems resulting from lack of tenderness, communication problems and feelings of guilt or pain. Generally, the prevalence of age-related female sexual dysfunction showed a strong correlation to depression, indicating that low desire is more common in women with comorbid medical and psychiatric disorders, particularly chronic illnesses and mood disorders[47].

In a longitudinal study of 438 Australian women aged 45-55 years, the investigators sought to assess the effect of menopause transition on sexual function[48]. Women were identified via random telephone calls and were eligible to participate if they were still menstruating at baseline. Subjects were classified as premenopausal, late premenopausal or postmenopausal and were followed-up for 8 years. A shortened version of the Personal Experiences Questionnaire (SPEQ) was administered annually to assess sexual functioning, with a total SPEQ score of 7 or less used to indicate sexual dysfunction. In this longitudinal study, sexual dysfunction increased twofold from early menopause to postmenopause (42 vs 88% women with sexual dysfunction).

Another survey of 580 menopausal women described the changes in female sexual desire occurring with the menopause transition. There was a gradual decline in sexual desire with age, but not in all women: 45% reported a decrease, in 37% there was no change and in 10% there was an increase in sexual desire occurring with menopause. Arousal decreases with menopause as genital perfusion, engorgement and vaginal lubrication decrease[49]. Orgasmic capacity is maintained; however, stimulation typically needs to be longer, more direct and more intense to lead to climax. Orgasm intensity decreases with more rapid resolution associated with decrease pelvic floor muscle tension.

Sex hormones have a modulating effect on female sexual function. Low estrogen levels are associated with vulvovaginal changes, including vaginal dryness and pain during vaginal penetration[50]. Low androgen levels are linked to decreased female sexual function, including decreased sexual desire, genital sensation and genital response[51]. The effects on sexual life, psychological well-being and androgen status were assessed after hysterectomy with or without removal of ovaries and estrogen replacement[52]. In this study, 101 women who underwent an abdominal hysterectomy completed the McCoy Sexual Rating scale and participated in a semistructured interview on libido, lubrication, ability to achieve orgasm, and pleasure from intercourse since their procedure. Of the women who did not undergo an oophorectomy, only 14% reported a decrease in libido, 66% reported that their libido was the same or better, and the balance (20%) had not been sexually active after the operation. Approximately 40% of those who underwent removal of their ovaries reported a decrease in libido. Estrogen-replacement therapy did not influence change in libido among the women who underwent an oophorectomy. These data suggest that hysterectomy with oophorectomy is associated with a decrease in libido, which is not corrected by estrogen-replacement therapy.


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