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Female sexuality and changes with age http://womenshealth.med.monash.edu.au Sexuality is an integral part of the human psyche and is present from birth to death in everyone. Sexuality is expressed throughout life in all people both consciously and unconsciously in body movements and body language, speech, appearance and in every imaginable way people interact with each other. The way people demonstrate their innate sexuality varies according to their stage of life. It is expressed in family intimacy and as part of play in childhood, more overtly in adolescence and in physical sexual activity throughout adult life. The importance of sexual health to overall health is often overlooked by health care professionals and society in general to the detriment of all. One cannot dismiss the impact that sexual health has on a woman’s general wellbeing. It’s as important as diet and exercise. According to the World Health Organisation: ‘Sexual health is a state of physical, emotional, mental and social well-being related to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviors, practices, roles and relationships. While sexuality can include all of these dimensions, not all of them are always experienced or expressed.’ Individual expression of sexuality is influenced by cultural and social environment, personal knowledge, past experiences and current expectations, physical and psychological well being and most importantly the availability of a partner. Sexual difficulties are common in women of all ages with reported prevalences ranging from 10 – 50 per cent. The diagnostic classifications of female sexual dysfunctions according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, revised are: • Hypoactive sexual desire disorder • Sexual arousal disorder • Orgasmic disorder • Dyspareunia (pain) • Other (eg. aversion) Hypoactive Sexual Desire Disorder (HSDD) is defined as the persistent or recurrent deficiency (or absence) of sexual fantasies/thoughts and/or desire for, or receptivity to, sexual activity, which causes personal distress (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, revised). This is believed to be intimately linked to low arousal and sexual responsiveness in women. Sexual function and ageing Although ageing per se interferes with the level of sexual performance, the improved health of older people and possibly altered expectations appear to have impacted on the sexual lives of older people over the last few decades. A Swedish study reported that sexual activity of 70 year-old women increased between 1971 and 2000 (Beckman 2008). The proportion of 70 year-olds reporting sexual intercourse increased in married women from 38 – 56 per cent (p=0.001) and in married men from 52 – 68 per cent (p=0.002). These data confirm that sexual activity remains an important part of life for many older women. Older women experience fewer sexual thoughts and fantasies, lessened vaginal lubrication with intercourse and less sexual satisfaction. For many women these changes are subtle and do not interfere with their overall sexual relationships. One of the greatest predictors of a woman having a satisfying sexual relationship or experiences after menopause is the quality of the sexual aspects of her life before menopause, with those most satisfied with this aspect of their life in the late premenopausal years least likely to report problems. The availability of an interested partner appears to be a critical factor for older women, who often attribute lessened sexual activity to impotence or illness in their partner. The physical changes resultant from both ageing and declining oestrogen levels affect female sexuality. In addition to circulating oestrogen levels falling at menopause, the nervous system and vascular system also decline with age. Loss of fat and glandular tissue combined with lessened muscle tone and tissue elasticity makes the breasts and other body regions more drooping and flabby. The cervix, uterus and ovaries shrink, the vagina becomes dry and the lining tissue thinner, and the clitoris, which retains its sensitivity, decreases in size. Oestrogen loss causes much of the discomfort of intercourse that may occur with ageing, and oestrogen therapy as vaginal oestrogen creams or pessaries will successfully reverse symptoms such as vaginal dryness and the contact bleeding with intercourse. The duration of orgasm is reduced in women over 50 years of age. In some women, uterine contractions during orgasm may become spasmodic and painful instead of being rhythmic and pleasurable. Alternatively, the contractions may become so mild in older women that they are not sure whether they have achieved orgasm. Resolution to an unstimulated state is more rapid in older women however women of all ages are able to experience multiple orgasms. Sexual arousal is achieved through touching, kissing, clitoral stimulation and erotic fantasies. In older women touch sensation is diminished as is vascular responsiveness, therefore nipple erection and genital response and congestion is lessened. Vaginal secretions are reduced and a longer time is required for adequate lubrication to occur. Although the clitoris becomes smaller with age, the response to stimulation remains intact, but it usually takes longer to achieve a sexual plateau. Female sexual dysfunction impacts adversely on self-esteem, quality of life, mood and relationships with sexual partners. It is associated with significantly lower health-related quality of life in women in general. Furthermore, sexual desire within a relationship is a key determinant of the quality of the nonsexual aspects of the relationship. Both men and women reporting a discrepancy between their own and their partner’s sexual desire have lower relationship satisfaction and individuals in sexually inactive marriages report less marital happiness. Fundamentally age is no deterrent to good sex. The changes of ageing may require some adjustments, but these can always be made to permit ongoing sexual activity. The impact of illness on sexual activity in women: Physically coitus is about as strenuous as a vigorous walk. For a woman with heart disease sexual activity is usually safe if she is able to climb a flight of stairs or walk briskly for 10–15 minutes without any distress. Diabetes is a common cause of loss of ability to sustain an erection in men, but does not appear to affect either sexual desire or performance in women. Urinary tract and vaginal infections such as thrush are more common in diabetics so practices such as emptying the bladder before and soon after intercourse are worthwhile. Anti-depressants are the most likely medications to suppress sexual function. Female sexual dysfunction is an established side-effect of antidepressant therapy, and is most frequently reported by women using selective serotonin reuptake inhibitor (SSRI) therapy. SSRIs are the most commonly used antidepressant by Australian women. An overall incidence of antidepressantrelated sexual dysfunction of 56.9 per cent has been reported in women, with SSRIs and venlafaxine (a serotonin and norepinephrine reuptake inhibitor; SNRI) having the most adverse effects. Sexual dysfunction in women being treated for depression is not only a recognised cause of cessation of therapy, but adversely affects personal wellbeing and relationship health, and is likely to contribute to treatment failure and consequent persistence of depression. Women on anti-depressants who experience diminished sexual desire or responsiveness should discuss this issue with their doctor. Sexual health after gynaecological and other cancers. This is an increasingly common problem which fortunately is being more openly discussed. The Cancer Council of Victoria has produced an excellent book for patients and their partners that comprehensively address this issue. Other cancer resource groups are also likely to have patient support information available. Partner health Many older women do not have a partner or are in a relationship with a person who suffers ill health or sexual dysfunction. Masturbation is less well accepted by women than men, but is an important sexual outlet for many women. Early research suggests that up to 25 per cent of women over the age of 70 masturbate. Mutual masturbation is a common healthy sexual practice for many couples that have ill health preventing vaginal intercourse. Summary The low level of sexual desire unfortunately expressed by so many older women often strongly reflects negative societal feedback on aging in general and sexual repression of older women specifically. Improving our attitudes towards ageing, increasing respect for older women in the community and liberalising our views regarding sexual expression in older people will hopefully enable older women to experience better sexual wellbeing. Women with concerns about their sexual life should find a doctor or counsellor with whom they feel comfortable discussing this very personal but important aspect of their life. Medications prescribed for various diseases can potentially affect female sexual function, but unfortunately have been little studied in women, as opposed to the vast literature on drug induced impotence in men. The information in this flyer was correct at the time of publication. Monash University reserves the right to alter this information should the need arise. Produced by the Women’s Health Program, Monash University © October 2010. CRICOS provider: Monash University 00008C MMS287303