Patterns and Predictors of Sexual Activity Among Women in the Hormone Therapy Trials of the Women's Health Initiative

Gass, Margery L.S. MD, NCMP; Cochrane, Barbara B. PhD, RN; Larson, Joseph C. MS; Manson, JoAnn E. MD, DrPH, NCMP; Barnabei, Vanessa M. MD, PhD, NCMP; Brzyski, Robert G. MD, PhD; Lane, Dorothy S. MD, MPH; LaValleur, June MD; Ockene, Judith K. PhD, MEd, MA; Mouton, Charles P. MD, MS; Barad, David H. MD, MS


Menopause. 2011;18(11):1160-1171. 

In This Article


Objective: The aim of this study was to determine the patterns and predictors of sexual activity in the Hormone Therapy (HT) Trials of the Women's Health Initiative (WHI).
Methods: Sexual activity questions were administered to 27,347 women ages 50 to 79 years at baseline and at year 1 and to a random 8.6% subsample at years 3 and 6. The associations with demographic and health characteristics were determined.
Results: Sexual activity at baseline was 60.7%, 44.9%, and 28.2% in the 50- to 59-, 60- to 69-, and 70- to 79-year-old age groups, respectively. Most of the participants were satisfied with their current sexual activity (63.2%). Of those dissatisfied, 57% preferred more sexual activity. Vaginal atrophy correlated with sexual inactivity at baseline (P < 0.001). The correlates associated with stopping sexual activity at year 1 included poor/fair self-rated health, lack of satisfaction with quality of life, depression, and loss of partner (P < 0.001). The strongest predictor of sexual activity at year 1 was sexual activity at baseline (odds ratio, 96.71; 95% CI, 81.90-114.20). A subset analysis of women adherent with HT or placebo at years 3 and 6 suggested that HT was associated with a higher percentage of participants reporting sexual activity (P = 0.01).
Conclusions: Most women in the WHI HT Trials were satisfied with their sexual activity. Of those who were dissatisfied, the majority preferred more, rather than less, sexual activity. Vaginal atrophy at baseline correlated with sexual inactivity, and sexual activity at baseline was the strongest identified predictor of sexual activity at year 1. HT use was not predictive of ongoing sexual activity in the intent-to-treat analysis. This report further characterizes the participants in the WHI HT trials and reveals the complexity of factors related to the prevalence of sexual activity and satisfaction.


Many women remain sexually active into their 70s.[1] Numerous reports have evaluated various predictors of ongoing sexual activity in cross-sectional studies,[2,3,4,5,6,7,8,9,10,11,12] but rarely has it been possible to follow a large cohort of older women prospectively in a randomized controlled trial that includes demographic and psychosocial information, sexual activity questions, hormone therapy (HT) use and physical findings. The Women's Health Initiative (WHI) HT Trials provided the opportunity to focus specifically on the presence or absence of sexual activity and on satisfaction with sexual activity, in relation to many variables that were not available in other studies.

Most reports indicate that age is a significant predictor of decreased sexual activity,[1,2,3,6,7,8,10] and the absence of an able partner has been reported by some to be the principal reason that middle-aged and older women are not sexually active.[6,7,12] Other factors associated with sexual activity in older women have included general health and physical condition, psychological and emotional issues, cultural attitudes, previous sexual experiences, self-image, hypoactive sexual desire, dyspareunia, relationship issues, and medications.[2,3,4,5,6,7,8,9,10,11,12,13]

Physical changes associated with menopause may have a negative effect on sexual function.[4,14,15,16] Vulvovaginal atrophy, as a physical change associated with menopause, can increase vaginal dryness, decrease vaginal elasticity, and serve as a deterrent to sexual activity.[14,15,16] HT can ameliorate some of these vulvovaginal changes and decrease the associated dyspareunia.[16,17] Pelvic organ prolapse and urinary incontinence are two additional gynecologic conditions not uncommon in postmenopausal women that may exert a negative impact on sexual function. These three conditions have been associated with decreased sexual function in some, but not all, reports.[18,19,20,21,22]

The WHI-HT trials collected information on many factors potentially relevant to women's sexual health, such as partner status, vaginal symptoms, pelvic relaxation, vulvovaginal atrophy, and incontinence. Barnabei et al[23] reported that, 1 year after randomization, the use of estrogen plus progestogen therapy (EPT) significantly reduced vaginal/genital dryness in symptomatic women and decreased the risk of this symptom in asymptomatic women compared with placebo use (P < 0.001). Brunner et al[24] published similar findings for the estrogen therapy (ET) trial. Conversely, Ockene et al[25] found that, 1 year after discontinuation of EPT, the participants reported an increase in vaginal dryness compared with placebo users (9.87% vs 5.1%, respectively). Both Hays et al[26] and Brunner et al[27] reported a lack of significant effect of HT on sexual satisfaction among women in the HT trials. In a cross-sectional analysis of sexual satisfaction in the WHI Observations Study (97,000 participants), McCall-Hosenfeld et al[28] similarly found no significant effect of HT on sexual satisfaction but noted negative correlates of sexual satisfaction, including poor health status, symptoms of depression, and the use of selective serotonin reuptake inhibitors.

The current analysis explores the relationship of HT, age, health, vulvovaginal atrophy, prolapse, partner, satisfaction, and other factors with sexual activity over time, as reported by participants in the WHI-HT trials.


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