What are the primary causes of decreased libido, arousal, and orgasm in aging women?

Primary Causes of Decreased Libido, Arousal, and Orgasm in Aging Women

The primary causes of decreased libido, arousal, and orgasm in aging women are declining estrogen and testosterone levels due to menopause, leading to physiological changes including vaginal atrophy, reduced lubrication, and altered hypothalamic-pituitary axis function. 1

Hormonal Factors

• Estrogen Decline:

  • Causes vulvovaginal atrophy, leading to vaginal dryness and reduced lubrication 1
  • Affects the hypothalamic-pituitary axis, disrupting normal sexual response 1
  • Results in decreased vaginal blood flow and diminished genital sensation 2
  • Leads to thinning of vaginal tissues, making intercourse painful (dyspareunia) 2

• Testosterone Reduction:

  • Significantly impacts libido/sexual desire 1
  • Affects orgasmic function - testosterone levels are positively linked to orgasm 3
  • Decreases with age and particularly after menopause 1

Physiological Changes

• Vaginal Changes:

  • Atrophic vaginitis affects approximately 50% of postmenopausal women 2
  • Unlike hot flashes which tend to resolve, vaginal symptoms persist indefinitely 2
  • Symptoms include vaginal dryness, discomfort, pruritis, and dyspareunia 2

• Sexual Response Changes:

  • Decreased vaginal lubrication (affects 20-48% of women) 1
  • Reduced arousal capacity and intensity 4
  • Difficulty achieving orgasm (affects 16-36% of women) 1
  • Painful intercourse (affects 35-38% of women) 1

Psychosocial Factors

• Psychological Aspects:

  • Depression and anxiety commonly contribute to sexual dysfunction 1
  • Changes in body image and self-perception affect sexual desire 2, 1
  • Decreased self-esteem impacts overall sexual functioning 3

• Relationship Factors:

  • Relationship satisfaction is a significant predictor of sexual functioning 3
  • Emotional support strongly correlates with healthy sexual function 3
  • Partner availability and partner function significantly impact sexual activity 5

Medical Comorbidities and Medications

• Health Conditions:

  • Cardiovascular disease 1
  • Diabetes 1
  • Liver disease (alters hormone metabolism) 2, 1

• Medications:

  • Antidepressants (particularly SSRIs) 1
  • Hormone therapies (aromatase inhibitors) 2, 1
  • Narcotics 1
  • Beta-blockers 1
  • Spironolactone 2, 1

Assessment Algorithm for Sexual Dysfunction in Aging Women

1. Screen for specific sexual concerns:

   • Decreased libido/desire (affects 23-64% of women) 1
   • Arousal or lubrication problems 1
   • Orgasmic difficulties 1
   • Pain with intercourse 1

2. Evaluate hormonal status:

   • Determine menopausal status 2
   • Assess for symptoms of vaginal atrophy 2

3. Review medical conditions and medications:

   • Identify conditions that may affect sexual function 1
   • Review medications with potential sexual side effects 1

4. Assess psychological and relationship factors:

   • Screen for depression and anxiety 2
   • Evaluate relationship satisfaction 3
   • Assess emotional support systems 3

Treatment Considerations

• Non-hormonal options:

  • Water-based lubricants and moisturizers for vaginal dryness 2
  • Silicone-based products may last longer than water-based products 2
  • Vaginal dilators and pelvic floor relaxation techniques for dyspareunia 2

• Hormonal therapies (with caution in certain populations):

  • Topical vaginal estrogen for atrophy 2
  • Ospemifene for dyspareunia (contraindicated in breast cancer survivors) 1, 6

• Psychosocial interventions:

  • Psychoeducational support 2
  • Sexual counseling 2
  • Marital/relationship counseling 2

Important Caveats

• Sexual dysfunction in aging women is often multifactorial, requiring assessment of both physiological and psychosocial factors 2
• Treatment should address underlying issues rather than just symptoms 2
• While hormonal changes are significant contributors, psychological factors like relationship satisfaction and emotional support are strong predictors of maintained sexual function 3
• Sexual concerns should be actively screened for, as many women are reluctant to initiate these discussions 2