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


This report is the first to summarize the responses to all the sexual activity questions in the WHI-HT trials. It documents the predictors of sexual activity and the patterns of change over time in the participants. Most women were married or were in an intimate relationship. Overall, women were satisfied with their current sexual activity and its frequency. In all age groups, partnered women were more likely to be satisfied with their sexual activity and its frequency compared with nonpartnered women. In spite of recent reports that have highlighted the high prevalence of hypoactive sexual desire disorder in females,[3,34,35] more women in the present study were dissatisfied with their sexual activity because they preferred more rather than less sexual activity. This was especially true in younger postmenopausal women with or without a partner.

Factors associated with discontinuing sexual activity between baseline and year 1 included poor self-rated health, dissatisfaction with quality of life, and, foremost, the loss of an able partner. These findings are consistent with earlier cross-sectional and longitudinal reports that state that the lack of a partner or partner illness is strongly associated with women's sexual satisfaction and with stopping sexual activity.[6,7,12,28] The strongest predictor of sexual activity at year 1 was the presence of sexual activity at baseline. It is plausible that the patterns of sexual activity of those who enrolled in WHI may have been so well established that the effect of adding or removing HT was not pronounced enough to change behavior.

HT was not a statistically significant determinant of sexual activity in this cohort of relatively healthy postmenopausal women despite a correlation with the presence of sexual activity at baseline. A possible explanation of these seemingly discrepant findings is that, before enrollment in WHI, the women who were sexually active may have used HT to make intercourse more comfortable. This same explanation may apply to women in the Melbourne Women's Midlife Health Project. This observational study of 257 Australian women aged 56 to 67 years reported that partnered women taking HT had a higher sexual function score on several parameters but had no difference in frequency of sexual activities compared with partnered women not taking HT.[36] A recent potentially related publication reported that low-dose HT decreased dryness and increased pleasure with intercourse for women but did not increase the frequency of intercourse.[37] Significant improvement in vaginal dryness has already been documented for the WHI-HT trials.[23,24] Other studies have indicated that previous function and relationship factors are more important than the hormonal determinants of sexual function.[5,38] The participants in WHI were not selected based on dyspareunia or vaginal dryness.

The strength of pre-existing sexual activity as a predictor of current sexual activity suggests that women who remain sexually active as they age are able to preserve sexual function despite declining hormone levels at menopause. Analysis of these data by age group did not change the overall findings. A subanalysis of the adherent group at year 6 was suggestive of a benefit over the long term, with regard to the continuation of sexual activity.

In this analysis, we were able to identify the factors associated with lower sexual activity prevalence rates, such as low income, certain health conditions, hysterectomy, daily leakage of urine, and physical examination evidence of vulvovaginal atrophy. However, these associations do not support a determination of cause and effect. The presence of vulvovaginal atrophy was associated with the lack of sexual activity at baseline but was not associated with stopping sexual activity between baseline and year 1. The timing of vulvovaginal atrophy vis-à-vis the cessation of sexual activity cannot be determined from these data because only a subsample of women completed the sexual activity items after year 1 and in that subsample, the questions on sexual activity were not completed as frequently as clinical assessments for vulvovaginal atrophy. Despite that limitation, the descriptive data suggest that the lack of sexual activity, vulvovaginal atrophy, and no history of HT use were associated at baseline and that the continuation of sexual activity and HT use were associated over time in participants adherent to the HT trials regimen.

Among women reporting vaginal dryness at baseline, a common symptom of vulvovaginal atrophy, 63% were sexually active at baseline and 34% were not. Among all women who were not sexually active at baseline, only 6.6% reported vaginal dryness compared with 13% of the sexually active women. Although many women with vulvovaginal atrophy are asymptomatic,[39] the decrease in moisture and natural lubrication can result in dyspareunia.[4,40,41] It is probable that women who are sexually active are more aware of vaginal dryness compared with women who are not sexually active. These findings suggest that vulvovaginal atrophy is largely asymptomatic in women who are not sexually active. Lending support to this interpretation is the report by Dennerstein and Lehert[42] stating that women reporting vaginal dryness were more likely to report dyspareunia (OR, 3.72; 95% CI, 2.97-4.65).

A history of pelvic organ prolapse was not associated with decreased sexual activity. In contrast to a recent analysis in reproductive-age women that found that a number of measures of sexual activity were not affected by BMI,[43] we found that higher BMI was associated with a lower likelihood of sexual activity in postmenopausal women.

The limitations of this report are noteworthy. Questions may arise as to the generalizability of the findings, especially in the 50- to 59-year-old age group. Women who reported severe vasomotor symptoms were advised not to enroll in the randomized trial because it was thought that they would drop out of the study if they were assigned to placebo. Although disproportionately low numbers of women with severe vasomotor symptoms could limit the generalizability of the findings reported here, a report on 3,302 perimenopausal women from the Study of Women's Health Across the Nation stated that vasomotor symptoms were not related to any sexual function outcome.[44] Because women who join clinical trials and adhere to study drugs may differ from nonadherent women, generalizing should be undertaken with caution.

A major limitation of the study relates to the small number of questions asked about sexual activity in the WHI, in contrast with other large studies focusing exclusively on sexual function and using more detailed measures.[1,3,8,36,37,38,41,42,44] Sexual function was not a principal outcome of the WHI study. This study has no information on the prevalence of masturbation or the types of sexual activity among partnered or single women. The interpretation of the term "sexual activity" was left to each participant. Some may have interpreted it as partnered activity, and some may have interpreted it as solo activity. Therefore, responses to these questions should be interpreted broadly. It was also not possible to determine the quantity of sexual activity or a relative increase or decrease in the amount of sexual activity. Nuances related to the level of sexual activity with regard to health, for example, would be missed.

The WHI sexual activity questions were administered at four time points, two of which included only a small subsample of participants, resulting in small numbers in some cells. Small cells can have an important effect when the findings are based on χ2 analyses.

This report is unique in having pelvic examination data regarding prolapse and vulvovaginal atrophy to complement the women's report of sexual activity. However, a potential weakness of this component is the lack of laboratory validation of atrophy by means of pH and vaginal maturation indices. In this study, the diagnosis of vaginal atrophy was made based on clinician assessment at each WHI site. Although pH and vaginal maturation indices provide a means of comparing populations across studies, they do not necessarily correlate with symptoms, as demonstrated by Davila et al.[39]

The participants discontinued study pills upon the diagnosis of breast cancer or cardiovascular event. These women may have been less likely to continue sexual activity after their health event, thereby confounding adherence data.

With infrequent assessments and lack of details about sexual activity, it is not possible to determine the causality for each association. For example, depressive symptoms could lead to the cessation of sexual activity; conversely, the lack of sexual activity could lead to depressive symptoms. The WHI cohort, with fewer cardiovascular risk factors than the general population, is not a representative population sample.[30] Finally, the participants were unselected with respect to sexual function. The effects of HT in postmenopausal women presenting with sexual symptoms of dryness and dyspareunia may be more pronounced and cannot be inferred from our observations. The failure to find a greater facilitating effect of HT on the persistence of sexual activity may indicate that many women continue to have sexual intercourse despite vaginal dryness and dyspareunia. This interpretation would be consistent with findings from the Study of Women's Health Across the Nation indicating no difference in the frequency of intercourse between premenopausal women and early perimenopausal women who reported greater pain with intercourse.[44] The recent increase in the use of vaginal estrogen products suggests that not all women are willing to endure the discomfort.[45]


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