How does menopause affect a woman's sex life?

Impact of Menopause on Women's Sexual Function

Menopause significantly affects women's sexual function through physiological changes that cause vaginal dryness, discomfort, pain during intercourse, and decreased libido, all of which can substantially reduce quality of life. 1, 2

Physical Changes Affecting Sexual Function

• Vaginal atrophy (atrophic vaginitis) affects approximately 50% of postmenopausal women, causing vaginal dryness, discomfort, pruritis, dyspareunia, urinary tract infections, and urinary urgency 1, 2
• Unlike hot flashes which tend to resolve over time, vaginal atrophy symptoms often persist indefinitely and may worsen with time 1, 3
• Low circulating estrogen levels cause thinning of vaginal tissues, decreased vaginal lubrication, and reduced pelvic support 3, 4
• Decreased blood flow to the genital area affects arousal capacity and ability to achieve orgasm 5
• Changes in body configuration and alterations in skin, breasts, muscles, and skeleton due to estrogen loss can negatively impact self-image 3

Psychological and Emotional Effects

• Decreased estrogen can lead to diminished self-esteem and reduced sexual desire 3, 6
• Many women experience global symptoms of distress, anxiety, or depression related to menopausal changes 1
• Societal expectations can negatively impact sexuality, as many cultures still believe older women become sexually retired 3
• Body image concerns may increase with physical changes associated with menopause 1
• Sexual difficulties are often multifactorial, involving both physiological and psychological components 1

Common Sexual Dysfunctions During Menopause

• Hypoactive sexual desire disorder (HSDD) is a persistent absence of sexual fantasies/thoughts and/or desire that causes personal distress 6
• Dyspareunia (pain during intercourse) is directly related to vaginal atrophy and dryness 7, 5
• Problems with orgasm (less intensity, difficulty achieving) become more common 1
• Decreased vaginal lubrication affects arousal and comfort during sexual activity 4, 5
• Partner availability and partner function also contribute to sexual difficulties 3

Treatment Options for Menopausal Sexual Dysfunction

Non-Hormonal Approaches (First-Line)

• Regular use of vaginal moisturizers can provide relief from dryness and discomfort for daily maintenance 2
• Water-based or silicone-based lubricants are recommended for use during sexual activity 1, 2
• Pelvic floor physical therapy can improve sexual pain, arousal, lubrication, and satisfaction 1, 2
• Vaginal dilators may help with pain during sexual activity and increase vaginal accommodation 2
• Integrative therapies such as yoga and meditation may help alleviate associated symptoms like anxiety 1

Hormonal Approaches (Second-Line)

• Vaginal estrogen (creams, tablets, rings) is the most effective treatment for vaginal dryness and associated symptoms when non-hormonal options fail 1, 2
• Low-dose formulations of vaginal estrogen minimize systemic absorption 2
• DHEA (prasterone) is FDA-approved for vaginal dryness and pain with sexual activity 2
• For women with low sexual desire, discussion of available drugs (androgens, flibanserin, bremelanotide) may be warranted 1, 2
• Ospemifene, a selective estrogen receptor modulator, is FDA-approved for moderate to severe dyspareunia in postmenopausal women but is contraindicated in women with a history of estrogen-dependent cancers 1, 8

Special Considerations

• For breast cancer survivors, non-hormonal options should be tried first; if vaginal estrogen is needed, risks and benefits should be carefully discussed 2
• Women on aromatase inhibitors experience more severe vaginal atrophy (18%) compared to those on tamoxifen (8%) 1
• Treatment non-compliance may lead to worsening symptoms and reduced quality of life 2
• Partner/spouse support is crucial to therapeutic success 1
• Regular assessment of sexual function should be part of routine healthcare for menopausal women 1

Screening and Assessment

• Healthcare providers should ask about sexual function at regular intervals 1
• The Brief Sexual Symptom Checklist can be used as a primary screening tool 1
• Review present and past levels of sexual activity and identify traditional risk factors (cardiovascular disease, diabetes mellitus, smoking, alcoholism, obesity) 1
• Assessment should include evaluation of symptoms related to vaginal health, pain with sexual activity, problems with orgasm, and issues with desire/libido 1