Quality of Sexual Life and Menopause

Kate Jane Eden; Kevan Richard Wylie

Disclosures

Women's Health. 2009;5(4):385-396. 

In This Article

Menopause Physiology, Symptoms & Impact on Quality of Life

Menopause: Hormonal Physiology

The hormonal outcome of the menopausal transition is a decrease in levels of estradiol and an increase in follicle-stimulating hormone with the late perimenopause and early postmenopause being the period over which the majority of change occurs.[21] Sex hormone-binding globulin (SHBG) and inhibin (A and B) also decrease towards postmenopause. Total testosterone decreases with increasing age throughout women's lives, with the peak decline occurring at the age of 30 years[21] and little variation occurring across the menopause transition, although free testosterone increases towards postmenopause owing to decreasing SHBG. Levels of dihydroepiandrosterone sulphate (DHEAS), a precursor to both estrogens and androgens, decrease with increasing age but are not associated with menopause status.[21] In menopause induced by bilateral oophrectomy, levels of estradiol and total testosterone decline sharply, resulting in more severe symptoms.

Impact of Menopausal Hormonal Physiology on Sexual Function

As previously outlined, the most common sexual complaints occurring around the time of menopause onset are lack of sexual desire or libido, lack of sexual arousal and vaginal dryness. The female sexual response is complex and is not yet fully understood, but the hormonal changes of menopause have been suggested to affect the sexual response through a variety of mechanisms, some of which have been more conclusively demonstrated than others.

Estrogens are responsible for maintaining the collagen, elastic fibres and vasculature of the urogenital tract that is essential for its structural and functional integrity. This hormone also maintains vaginal pH and moisture levels, keeping the tissues lubricated and protected. Prolonged estrogen deficiency, as occurs in menopause, results in atrophy, fibrosis and reduced blood flow to the urogenital tract,[13] causing the symptoms of vaginal dryness, soreness and pain related to sexual intercourse dyspareunia).

Dennerstein et al. tracked the serum estradiol levels of 226 Australian women aged 45–55 years, who were still menstruating at baseline, across the menopause transition and compared estradiol levels with scores indicating sexual function. They found that women with low sexual function scores had lower estradiol levels compared with those with higher scores, particularly in the area of vaginal dryness and dyspareunia.[22]

The role of androgens in the female sexual response is particularly unclear and controversial. Suggested symptoms of androgen deficiency in women include decreased libido, fatigue and a reduced sense of wellbeing. Some studies support an association between low free-testosterone levels and low libido,[23] whereas others show no correlation between testosterone levels and sexual function[22,24,25]

Davis et al. compared serum levels of total and free testosterone, androstenedione and DHEAS in a cohort of 1021 women aged 18–75 years against validated measures of sexual function.[24] This study concluded that there was no clinically significant link between having low serum total testosterone, free testosterone or androstenedione and sexual function. However, there was a significantly increased likelihood of having low serum DHEAS and poor sexual responsiveness in older women.[24] Gracia et al. found a similar association between decreased serum DHEAS levels and decreased sexual function.[26] Alternative studies have found no correlation between DHEAS and sexual function.[22]

Symptoms of Menopause

A wide variety of symptoms have been linked with the menopause transition that may have a detrimental effect on a woman's quality of life, and directly, or indirectly, affect her sexual life. It is important to note that not all women will experience these symptoms[27] and that those who experience symptoms may not necessarily find the symptoms bothersome.

The most frequently reported symptoms that are popularly attributed to the menopause include vasomotor symptoms, such as hot flushes and night sweats, and urogenital problems, such as vaginal dryness or soreness.[9,28] Other complaints include sexual dysfunctions, such as low libido, incontinence, somatic aches and pains, fatigue and sleep disturbances, mood changes, such as increased irritability, cognitive changes, such as forgetfulness, and psychological disturbances, such as anxiety and depression.[9]

As discussed in this review, which of these symptoms result from the menopause transition itself, and which result from the aging process or other factors, including prior health and psychosocial factors, is a subject of much clinical research. The current consensus of the NIH is that only hot flushes, night sweats and vaginal dryness can be conclusively linked to menopause, with some evidence of a link between menopause and sleep disturbance.[27]

Vasomotor Symptoms

A total of 75% of women have been demonstrated to experience a bothersome hot flush at some time during the menopausal transition[21] with the incidence found appearing to vary with menopausal status. In premenopausal women, the incidence of vasomotor symptoms is reported to be 21%, increasing to 38% in early perimenopause, reaching a peak of 55% in late perimenopause and then declining to 44% in postmenopause.[29] Ethnicity also impacts on the reporting of symptoms with African–American women most likely to report vasomotor symptoms and Chinese and Japanese women the least likely to report symptoms.[29]

Urogenital Symptoms

The link between urogenital symptoms (e.g., vaginal dryness, soreness and dyspareunia) and menopause transition is clear, with vaginal dryness in particular increasing from early to late perimenopause by 13–16%.[29]

Mood Disturbances & Depression

The cultural stereotype of the menopausal woman as moody and irritable may stem from the commonly held belief among women and physicians alike that menopause causes depression and negative mood. However, evidence of a direct link between menopausal status and depression appears to be conflicting in the present literature, with some studies supporting a link,[30] others finding only a modest increase in depression[8] and further studies concluding that from early to late menopause transition, negative mood improves and positive mood does not change.[21]

Analysis of data from the Massachusetts Women's Health Study (MWHS), a prospective study of 2565 women aged 45–55 years, indicates that prior depression is the variable that is most predictive of subsequent depression in menopause.[8] This conclusion is supported by findings from the Melbourne Women's Midlife Health Project (MWMHP), another significant prospective study of 438 women aged 45–55 years, which concluded that the magnitude of negative mood in menopause is determined by prior experience of negative mood.[21] Other factors demonstrated to be predictive of depression in menopause include severe menopausal symptoms, high stress and daily hassles, negativity towards their partner, cigarette smoking, low exercise and poor self-reported health.[8,21]

Such findings are highly relevant to clinical practice, indicating that it should not be automatically assumed that depression in midlife women is due to the menopause, and other possible contributors to depression should be considered and addressed.[31]

Effect of Menopausal Symptoms on Overall Quality of Life

Initial small, patient-based studies have indicated that women felt their quality of life was severely compromised by menopausal symptoms[32] and further studies concluded that menopause brings about a significant decrease in quality of life that is independent of other factors, such as age, marital status and other sociodemographic variables.[33] Research from the MWMHP revealed a temporary decrease in wellbeing associated with increasing menopausal status, with the lowest wellbeing recorded in women 1–2 years postmenopause. This was only transitory, with a return to increased levels of wellbeing recorded in those more than 2 years postmenopause.[34]

Alternative research from practice-based populations, using validated instruments and cross-sectional design, has demonstrated that quality of life is mainly influenced by socioeconomic and cultural factors, rather than menopause itself.[35] Prospective, longitudinal research conducted as part of the Study of Women's Health Across the Nation (SWAN) indicates that menopausal status and symptoms do not affect quality of life, the strongest predictors for quality of life being stress and marital status, with attitude towards aging a contributing factor.[36]

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