What causes low libido, arousal, orgasm, and genital sensation in postmenopausal (post-menopausal) women?

Causes of Low Libido, Arousal, Orgasm, and Genital Sensation in Aging Women

The primary causes of sexual dysfunction in postmenopausal women include hormonal changes (particularly estrogen deficiency), physiological aging, psychological factors, relationship issues, and medical comorbidities, all of which can significantly impact quality of life and require appropriate assessment and treatment.

Hormonal Factors

Estrogen Deficiency

• Decreased estrogen levels lead to vulvovaginal atrophy, causing:
  • Vaginal dryness and reduced lubrication 1, 2
  • Vaginal irritation and itching 2
  • Dyspareunia (painful intercourse) 1
  • Reduced vaginal blood flow affecting arousal 2
  • Decreased genital sensation 1

Other Hormonal Changes

• Altered estrogen metabolism affects the hypothalamic-pituitary axis 1
• Reduced testosterone levels may contribute to decreased libido 1

Physiological Changes

Genital and Urinary Tract Changes

• Thinning of vaginal epithelium 2
• Decreased vaginal elasticity 2
• Reduced vaginal blood flow affecting arousal capacity 2
• Urogenital atrophy leading to discomfort 1

Sensory Changes

• Reduced capacity for arousal and orgasm 2
• Decreased intensity of orgasms 3
• Reduced sexual sensitivity of skin 1

Psychological Factors

Mental Health

• Depression and anxiety commonly contribute to sexual dysfunction 1
• Emotional lability affecting feelings of attractiveness 1
• Stress and psychological distress 4

Body Image Concerns

• Negative body image 4
• Changes in physical appearance affecting self-perception 1

Relationship Factors

Partner Issues

• Partner's erectile dysfunction or sexual health problems 4, 5
• Lack of an available partner 5
• Communication difficulties about sexual needs 4
• Quality of relationship 6

Medical and Medication Factors

Medical Conditions

• Chronic pain and fatigue 4
• Cardiovascular disease 1
• Diabetes 1
• Liver disease (altered hormone metabolism) 1

Medications

• Antidepressants (particularly SSRIs) 1
• Hormone therapy (aromatase inhibitors) 1
• Narcotics 1
• Beta-blockers 1
• Spironolactone 1

Assessment Algorithm

1. Screen for sexual dysfunction symptoms:

   • Decreased libido/desire (affects 23-64% of postmenopausal women) 1
   • Arousal or lubrication problems (affects 20-48%) 1
   • Orgasmic concerns (affects 16-36%) 1
   • Dyspareunia (affects 35-38%) 1

2. Evaluate for reversible contributing factors:

   • Medication review (especially antidepressants, narcotics) 1
   • Assessment for depression/anxiety 1
   • Evaluation of relationship factors 4
   • Physical examination for vulvovaginal atrophy 2

3. Consider validated assessment tools:

   • Female Sexual Function Index (FSFI) 7
   • Brief Sexual Symptom Checklist for Women 1, 7
   • Changes in Sexual Functioning Questionnaire 7

Treatment Considerations

Non-pharmacological Approaches

• Water-based lubricants and moisturizers for vaginal dryness 1
• Silicone-based products (may last longer than water-based) 1
• Vaginal dilators for dyspareunia 1
• Pelvic floor relaxation techniques 1
• Vibrators or clitoral stimulatory devices for orgasmic difficulties 1

Pharmacological Options

• For vaginal symptoms:
  • Non-hormonal vaginal moisturizers and lubricants (first-line) 1
  • Topical vaginal estrogen for atrophy (with caution in breast cancer survivors) 1, 2
  • Ospemifene for dyspareunia (not for breast cancer survivors) 1
  • Topical anesthetics for pain with sexual activity 1

Psychological Support

• Psychoeducational support 1
• Sexual counseling 1
• Marital/relationship counseling 1

Important Caveats

• Sexual dysfunction in aging women should not be automatically attributed to "normal aging" 4
• Many contributing factors are addressable with appropriate intervention 4
• Safety of hormonal therapies in women with history of breast cancer is not well established 1
• Use of hormonal therapies for women on aromatase inhibitors is not recommended 1
• Sexual function assessment should be part of routine healthcare for aging women 5