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

Disclosures

Menopause. 2011;18(11):1160-1171. 

In This Article

Results

Baseline Data

Baseline characteristics of sexually active, inactive, and nonresponding WHI-HT trial participants (EPT and ET trials combined) are reported in Table 1 . Most participants (73.1%) answered all six sexual activity items. Only 1.6% chose not to answer any of the questions, representing 0.9% of women with a partner and 2.0% of women without a partner. The decision not to answer any of the questions was also associated with older age (P = 0.02).

Among all participants at baseline, 49.6% indicated that they had sexual activity in the past year. A majority of participants in the study reported that they were married or were in an intimate relationship with at least one person (n = 16,911 or 61.8% of all HT trial participants). Among these women, 69.8% had sexual activity in the past year.

Overall, 355 women (1.3% of all HT trial participants) indicated they had never had sex, 135 (0.5%) defined themselves as lesbian, 188 (0.7%) identified themselves as bisexual, and 736 (2.7%) preferred not to answer the sexual orientation item. Women who preferred not to answer this item were more likely to indicate that they were sexually inactive.

At baseline, older women, women in lower income brackets, and women who were not married or in an intimate relationship were less likely to report sexual activity with a partner in the last year (P < 0.001). Women with a higher BMI were also less likely to report sexual activity, as were women with a history of health problems, such as myocardial infarction, arthritis, use of antidepressants, and poor to fair self-rated health (P < 0.001). The prevalence of vulvovaginal atrophy among all HT trial participants at baseline was 69%. Those with a clinical assessment of vulvovaginal atrophy were more likely to report sexual inactivity (P < 0.001). However, those women who reported moderate/severe genital dryness were more likely to report being sexually active than did those reporting no or mild genital dryness (P < 0.001). Recent or past use of HT correlated with the report of sexual activity (P < 0.001).

Sexual Activity Over Time

Table 2 identifies the health, symptom, and life event variables associated with discontinuing or continuing sexual activity over the first year after randomization among HT trial participants (active and placebo combined) who were sexually active at baseline. Conditions reported at year 1 that were significantly associated with stopping sexual activity between baseline and year 1 included depression, poor to fair self-rated health, and lack of satisfaction with quality of life (P < 0.001). Among women who reported being sexually active at baseline, a report of partner death or illness or divorce or separation in the previous year was significantly associated with stopping sexual activity in year 1 compared with women who did not report these events (P < 0.001). In general, a new diagnosis of cancer, cardiovascular event, or other health condition between baseline and year 1 was not associated with stopping sexual activity in the last year among those women who reported sexual activity at baseline (P ≥ 0.09), but the number of events was small.

Table 3 shows the responses by all HT trial participants (active and placebo combined) to the sexual activity items at baseline and year 1 and by the 8.6% subsample of participants in years 3 and 6, classified by age group. The number and percentage of women who were in intimate partnered relationships decreased with age group and time from a high of 70.2% in the 50- to 54-year-old age group at baseline to a low of 37.7% partnered at year 6 in the 8.6% subsample of women aged 70 to 79 years at baseline. A significant downward trend with age in the percentage of participants with partners was seen at all time points (P < 0.001 for all). Reported sexual activity with a partner in the last year also decreased as age group increased at all time points (P < 0.001 for trend).

Generally, satisfaction with current sexual activity tended to decrease over time from 63.2% (baseline) to 56.2% (year 6 subsample) among women with a partner and 42.4% (baseline) to 39.7% (year 6 subsample) in women without a partner. Satisfaction with the current frequency of sexual activity among women with a partner also tended to decrease from baseline to year 6, except in the youngest age group, women 50 to 54 years old at baseline. Table 3 documents a notably lower percentage of women without a partner who were satisfied with their frequency of sexual activity at each time point and for each age group. In a separate analysis of all women who were dissatisfied with their sexual activity at baseline, 57% indicated that they would have preferred more sexual activity, 8% preferred less, 25% were satisfied with the frequency of sexual activity, and 10% had no response. Age trends for satisfaction with sexual activity at each time point differed somewhat between women with and those without a partner at the same time point. In particular, among the women without a partner, age trends for satisfaction with current sexual activity showed increased satisfaction with increasing age groups across the baseline and year 1 values (P < 0.001 for trend), whereas age trends for women with a partner generally showed decreased satisfaction with increasing age groups across each time point (P = 0.012 for trend at year 1). In a separate analysis, younger women who indicated no sexual activity in the last year reported more dissatisfaction with the lack of sexual activity than did older women.

Overall, most (82.5%-86.4% across age groups) women reported being "not at all worried" that sexual activity would affect their health. However, older women generally indicated more worry than did the younger women during the course of the study.

Vulvovaginal Atrophy

Vulvovaginal atrophy was assessed annually only in EPT trial participants. The percentage of participants with atrophy generally increased with increasing age at all time points, even among the women assigned to active hormones (P < 0.001 for age trend). Sexual activity decreased by age group, regardless of vulvovaginal atrophy status (P < 0.001 for age trend).

Effects of HT Treatment Assignment

There was no statistically significant correlation of HT with the continuation of sexual activity in the intent-to-treat model including all participants, partnered or not, over time (Figure 2). With use of an unadjusted linear repeated-measures model, HT treatment assignment seemed to have an association with the persistence of sexual activity over time in adherent women who were taking 80% or greater of the assigned study pill regimen (Figure 3, P = 0.01 for HT treatment assignment). However, this association was nonsignificant when only those adherent women who were partnered were analyzed (P = 0.07). Analysis of the data by age group failed to find a trend for age at initiation.

Figure 2.

Percentage of participants in the Hormone Therapy (HT) trials reporting sexual activity in the last year by treatment arm at baseline, total group versus partnered participants. P = 0.08 (overall) and 0.26 (partnered) for HT treatment assignment from a repeated-measures model using years 1, 3, and 6. *Years 3 and 6 assessments were in a randomized 8.6% subsample.

Figure 3.

Percentage of adherent Hormone Therapy (HT) trial participants reporting sexual activity in the last year by treatment arm at baseline, total group versus partnered participants. P = 0.011 (overall) and 0.067 (partnered) for HT treatment assignment from a repeated-measures model using years 1, 3, and 6. *Years 3 and 6 assessments were in a randomized 8.6% subsample.

Table 4 reports the effects of EPT treatment assignment on sexual activity at year 1, adjusted for baseline sexual activity, age, smoking status, BMI, and WHI Dietary Modification trial treatment assignment, among EPT trial participants with a partner at baseline (ET trial participants did not have pelvic examinations during follow-up). EPT was not associated with an increased likelihood of reporting sexual activity during the preceding year at the year 1 visit compared with placebo (odds ratio [OR], 1.04; 95% CI, 0.90-1.21). When only those women who were taking at least 80% of their intervention pills in year 1 were included, this OR still failed to be statistically significant. Consistent with this finding, vulvovaginal atrophy was not predictive of year 1 sexual activity ( Table 2 ).

Sexual activity at baseline was highly predictive of sexual activity at year 1 (OR, 96.71; 95% CI, 81.90-114.20). In addition, each 5-year increment in age predicted decreased sexual activity (OR, 0.80; 95% CI, 0.76-0.85). Year 1 sexual activity was less probable among women who were past or current smokers (OR, 0.76; 95% CI, 0.64-0.89 and OR, 0.68; 95% CI, 0.52-0.89, respectively) and among women with a higher BMI (at 5-kg/m2 increments: OR, 0.92; 95% CI, 0.86-0.99).

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