Sexual Behaviors and Function During Menopausal Transition—Does Menopausal Hormonal Therapy Play a Role?

Krzysztof Nowosielski, MD; Marcin Sidorowicz, MD, PhD


Menopause. 2021;28(3):271-283. 

In This Article

Abstract and Introduction


Objectives: The menopausal transition is a biological adaptation to the variety of life changes (body, comorbidities, relationship), but that biology is not an "end all" in the context of sexual function and overall sexual health. The aim of this study is to evaluate determinants altering the risk of female sexual dysfunction (FSD) and other sexual problems and to establish whether menopausal hormonal therapy (MHT) decreases that risk and modifies sexual behaviors.

Methods: A cross-sectional observational study was conducted in 210 women between the ages of 45 and 55. Two groups were identified: MHT users (n = 107) and controls—MHT non-users (n = 103). Diagnostic and Statistical Manual of Mental Disorders -five criteria were used to assess sexual dysfunction. Sexual problems were evaluated by the Changes in Sexual Function Questionnaire (CSFQ), body image by Body Exposure during Sexual Activity Questionnaire, and quality of relationship by the Well-Match Relationship Questionnaire. Logistic regression was used to determine the risk factors for FSD and sexual problems.

Results: Women using MHT had higher body esteem during sexual activities, better sexual function (CSFQ) in all domains except desire/interest, better quality of relationship, and lower prevalence of FSD and sexual complaints (CSFQ) except arousal/excitement problems. However, self-rated effects of MHT on sexual behaviors showed that MHT did not play a major role. Women with secondary and higher education (OR = 0.09, CI: 0.02–0.4; P < 0.01 and OR = 0.2, CI: 0.05–1.0; P < 0.05, respectively) and with a higher number of lifetime sexual partners (OR = 0.6, CI: 0.4–0.9; P < 0.01) were less likely to have FSD. In contrast, individuals with more anxious behaviors during sexual activity (OR = 3.2, CI: 1.3–7.3; P < 0.01) and with more severe menopausal symptoms (OR = 1.1, CI: 1.0–1.2; P < 0.001) were more likely to have FSD. Using MHT was not associated with that risk nor with sexual function.

Conclusion: In women during menopausal transition, sexual behaviors were different in MHT users compared with non-users. However, in this cross-sectional observational study conducted in 210 women between the ages of 45 to 55 years, using MHT was not associated with modification of sexual function, decreasing the risk of sexual dysfunction, nor sexual problems.

Video Summary:


The physiological changes that occur during menopausal transition (1–3 y before menopause; also called perimenopause) and early postmenopause (1–6 y after menopause, according to STAW + 10 criteria)[1] interfere with cardiovascular and metabolic health, connective tissue quality, musculoskeletal and bone health, cognitive function, mood, sleep, and sexual function.[2,3] Declines in estrogen and testosterone levels, as well as lowered concentrations of other hormones, neurotransmitters, and neuromodulators, lead to genitourinary symptoms of menopause, vasomotor symptoms, decreased libido and arousal (Female Sexual Interest/Arousal Disorder [FSIAD]), low orgasm capacity (Female Orgasmic Disorder [FOD]), painful intercourse (Genito-Pelvic Pain Penetration Disorder), and lack of sexual activity.[4,5] The mechanisms underlying all of these alterations are complex—with biological, social, psychological, body satisfaction-related, and relationship factors playing a role.[2–5]

The prevalence of sexual dysfunction in general populations of women and in perimenopausal women varies between different studies. The numbers depend on geographic region, eligible population, socioeconomic differences, and criteria used (ie, The Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria, questionnaire-based criteria, presence of distress).[6–10] Based on DSM criteria, Female Sexual Dysfunction (FSD) was reported in 7% to 23% of women,[8,10] with desire disorders being the most prevalent (12.4%) in women between the ages of 45 and 54 in the latest population-based study in the US.[11] However, when questionnaire-based criteria (sexual problems based on Female Sexual Function Index (FSFI) plus sexual distress based on Female Sexual Distress Scale) were used, the number increased to 56.7% in all women between 20 and 80 years of age.[12] Any self-reported sexual problems were also reported in up to 62% of women, with decreased desire and arousal being the most prevalent issue.[13–15] Similarly, when sexual distress was a criterion, the incidence of FSD dropped from 69% to 25% in the study by Berra et al[16] and from 60.5% to 16.7% in Ringa et al's study.[17] Finally, based on the DSM-IV criteria, 48% of perimenopausal women were diagnosed with FSD.[9]

According to current perceptions of multifactorial, biopsychosocial conditioning of sexual function, sexual problems that emerge during menopausal transition might be a result of interactions between attachment styles, mood (depressive symptoms, anxiety), stress, psychoactive and other medication use, hormonal treatment (menopausal hormone therapy [MHT], hormone contraceptives), childhood experiences, onset of sexual activity, personality, cognitive schemas, infertility concerns, sexual expectations and beliefs, relationship context and quality, current health-related factors, social and educational context, smoking and drinking habits, diet, partner availability, as well as presence of cognitive distraction.[18]

Studies that have evaluated the influence of menopausal symptoms on sexual function have not presented clear conclusions thus far. The majority of research shows that symptoms increase the risk of FSD by up to 10-fold[19] and double that risk in women without partners.[20] Menopausal symptoms cause cessation of sexual activity in 20% to 80%,[21,22] reduce the chance of having a partner,[22] increase the risk of low desire and arousal,[13,23,24] increase pain during sex by 2-fold (found only in univariate and not multivariate analysis, indicating that other factors may also be involved),[13] lower frequency of sex,[24] lower quality of sexual life,[21] and impair sexual function.[22,23] However, recent analyses have revealed that urogenital and psychological symptoms of menopause might work indirectly on sexual response by acting through body image, depressive symptoms, and sexual communication in partnered women.[4]

While the menopausal transition is not a silent passage from reproductive age to old age, more research is needed to evaluate factors affecting sexual function in that period of time. This study was designed to examine some of these factors and aimed to evaluate sexual function in Polish women during menopausal transition to describe the prevalence of FSD based on DSM-5 criteria, to evaluate whether MHT influences sexual function, and to assess other factors that might modify the sexual functioning of perimenopausal women. The authors of this study believe that knowing possible modifying factors might help implement long and short-term medical interventions that focus not only on "fixing" or treating declines in sex hormones, but more on psychosexual behaviors and attitudes related to building sexual self-worth and consciousness, of both women and their partners, as women enter menopausal transition.